Oncology

Oncology

General Information  Definitions

 cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues  cancer types

 lymphoma and myeloma: cancers that begin in the cells of the immune system

 carcinoma: cancer that begins in the skin or in tissues that line or cover internal organs

 leukemia: cancer that starts in blood-forming tissue, e.g., bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood

 sarcoma: cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue

 central nervous system cancers: cancers that begin in the tissues of the brain and spinal cord

 types of tumors

 benign: refers to a tumor or growth that is not cancerous

 malignant: the uncontrolled growth of abnormal cells in the body, i.e., cancerous cells, which are spread through metastasis

 metastatic cancer: cancer that has spread from the place where it first started (primary site or site of origin) to another place in the body (the secondary site)

 almost any cancer can form metastatic tumors  most common sites of cancer metastasis: lungs,

bones, liver 

Read the World Health Organization's Cancer Fact Sheet for information about the impact of cancer worldwide.

5. staging: describes and classifies extent or spread of malignancy (most, but not all, cancers are staged this way)

Cancer Staging

Cancer Staging

Extent of Malignancy

T based on the size of the original (primary) tumor and whether or not it has grown into nearby tissues

N whether or not the cancer has spread to the nearby lymph nodes

M whether or not the cancer has spread to distant areas of the body TNM or Modified Duke System

Developed by the American Joint Committee on Cancer

6. grading: describes the degree of malignancy according to the type of tumor cell o indicates the degree of cell undifferentiation

o cancers with more abnormal-looking cells tend to grow and spread faster

Cancer Grading Degree of Malignancy

stage 0 carcinoma in situ

stage I localized with tumor limited to the tissue of origin

stage II limited spread

stage III extensive local and regional spreading

stage IV distant metastasis

Most cancers are graded using a number from 1 to 3 or 4; the lower the number, the more the cancer cells look like normal tissue.

2. Etiology

o generally unknown but may be caused by interacting factors

o cellular changes result from an interaction between a person's genetic factors and 3 categories of external agents

 physical carcinogens, e.g., ultraviolet radiation

 chemical carcinogens, e.g., asbestos, components of tobacco smoke, arsenic

 biological carcinogens, e.g. infections from certain viruses, bacteria or parasites

o familial risk for certain cancers, e.g., lung, stomach, breast, colon, rectum, and uterine

o cancer is the second most common cause of death in the U.S

 leading causes of cancer death among men: lung, prostate, colorectal, liver

 leading causes of cancer death among women: lung, breast, colorectal (see risk factors for developing breast cancer)



The National Cancer Institute has information about the cause,

diagnosis, prevention, and treatment and the continuing care of cancer patients and their families.

Learn more about cancer and prevention at the American Cancer Society Web site.

3. Warning signs: The seven warning signs of cancer (see below) and cancer screening recommendations

Seven Warning Signs of Cancer

C Change in bowel or bladder habits

A A sore that does not heal

U Unusual bleeding or discharge from any part of the body

T Thickening or a lump in the breast or elsewhere

I Indigestion or difficulty swallowing

O Obvious change in a wart or mole

N Nagging cough or hoarseness

National Cancer Institute, U.S. National Institutes of Health

4. Diagnostics

o history and physical exam - depends on location of tumor o radiographic studies, e.g., chest x-ray, mammogram o biopsy: obtaining tissue for histological examination

 needle biopsy: aspiration of cells

 incisional biopsy: removal of a wedge of suspected tissue from a larger mass

 excisional biopsy: complete removal of entire lesion or mass  staging biopsy: multiple needle or incisional biopsies of suspected

metastasis

 sentinel lymph node biopsy (SLNB): to determine extent (stage) of cancer

 vacuum-assisted biopsy: vacuum-assisted tissue biopsy (ex: Mammotome breast biopsy)

o cytological studies, e.g., Papanicolaou's (Pap) smear o proctoscopic examination, including guaiac for occult blood o liver function studies

o imaging - using computerized tomography (CT scan), magnetic resonance imaging (MRI)

o tumor markers - identifying biochemicals made and released by tumor cells, e.g., prostate-specific antigen (PSA), carcinoembryonic antigen (CEA),

alpha-fetoprotein

5. Treatment - based on stage and grade of tumor, treatment objective is to remove all traces of the cancerous tissue

o surgery - specific to site and type of malignancy

o chemotherapy - use of chemical agents in the treatment or control of the disease (adjuvant therapy)

How Chemotherapy Treatments Are Delivered

topical oral sublingual

subcutaneous intramuscular intravenous

PICC line non-tunneled catheters tunneled catheters

intraventricular (ommaya reservoir) & intrathecal (lumbar puncture)

intraperitoneal (single use, Tenckhoff catheters, Port-a-cath)

intra-arterial

intravesicular (med given through urinary catheter directly into the bladder)

intrapleural (chemo is inserted into a chest tube to control malignant pleural effusions)

implantable (wafers with meds are implanted in former site of brain tumor to kill tumor cells)

o radiation therapy - destroys cancer cells, with minimal exposure of normal cells to the damaging effects of radiation (adjuvant therapy)

 external beam radiation (the source of the radiation is external to the client)  brachytherapy: the radiation source comes into direct, continuous contact

with tumor tissues for a specific time (the source of the radiation is within the client)

1. unsealed radiation source - administration is by oral or intravenous route or by installation into a body cavity

2. sealed radiation source - solid implant is implanted with the tumor target tissues

 see lesson 7: Reduction of Risk Potential for more information about radiation therapy

o biologic therapy - typically used along with conventional cancer treatments (adjuvant therapy)

 immunotherapy - helps repair, stimulate or enhance the body's natural ability to fight cancer, including cancer vaccines, interferons, and interleukin 2 treatments

 targeted therapy - non-chemotherapy drugs used to target cancer cells  monoclonal antibodies: artificially produced antibodies that act against a

particular antigen, including trastuzumab (Herceptin), etanercept (Enbrel), infliximab (Remicade), abciximab (Reopro)

 tyrosine kinase: inhibits growth of cancer cells, such gefitinib (Iressa) for lung cancer, lapatinib (Tykerb) for breast cancer, and sunitinib (Sutent) for renal cell carcinoma

o bone marrow transplantation o stem cell transplantation 6. Nursing interventions

o monitor for effectiveness of all medications o monitor vital signs

o monitor for post-operative surgical complications o monitor intake and output

o monitor diagnostic tests and laboratory values, e.g., white blood cell and platelet counts

o monitor for fever, sore throat, unusual bleeding, or findings of infection  common sites of infection: skin, respiratory and gastrointestinal tracts  ensure frequent and thorough hand hygiene by client, family, staff

o administer chemotherapy as prescribed - usually only chemotherapy certified nurses can administer

 intravenous route is most commonly used

 dosing based on total body surface area (BSA), which requires a current and accurate height and weight

 have another RN double-check medication and dosage, both on the order sheet and with the drug itself

 prepare in air-vented space (biohazard cabinet area); wear gloves, gown, eye protection and mask when handling IV medications

 carefully monitor for phlebitis and extravasation

1. stop infusion and notify physician with extravasation

2. treatment may include elevating the extremity, heat or ice application (dependent upon medication), injection of antidote into site



The Oncology Nursing Society offers a competency course for nurses responsible for administering chemotherapy.

8. monitor side effects of chemotherapy and treat as indicated o fatigue

 allow adequate rest periods during care o alopecia

o nutrition

 assist client in selecting a well-balanced diet

 provide small, frequent meals (high calorie, high protein, high carbohydrate) that require less chewing (soft foods)

 provide protein supplements as prescribed

 loss of appetite may be the result of taste changes or a bitter taste in the mouth from medications

o nausea and vomiting

 administer antiemetics, e.g., ondansetron (Zofran), several hours before chemotherapy and for 12 to 48 hours afterwards, as prescribed  delayed nausea and vomiting can occur 7 days post administration o mucositis

 provide mouth rinses every 12 hours, e.g., saline or sodium bicarbonate and water, as prescribed

 offer complete mouth care before and after every meal; instruct client to use soft toothbrush and avoid dental floss

 administer topical anesthetic agents to mouth sores as prescribed  avoid hard or spicy foods

 avoid use of alcohol- or glycerin-based mouthwashes or swabs o skin changes

 use electric razor for shaving

 avoid rectal suppositories, enemas, and rectal thermometers

o myelosuppression: bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, platelets

 monitor lab values for neutropenia anemia and thrombocytopenia  initiate neutropenic precautions if white blood cell count decreases  monitor for petechiae, ecchymosis, bleeding of the gums, and

nosebleeds (due to decreased platelet count)  avoid intramuscular injections and venipunctures  administer blood products for anemia as prescribed o monitor for signs of anaphylactic reaction

 obtain allergy history

 administer test dose if prescribed by physician

 have emergency equipment and medications available

 most reactions occur within 15 minutes of starting the infusion  interventions

 stop the medication  maintain airway  notify physician

 maintain IV access with 0.9% normal saline

 place client in supine position with feet elevated (unless contraindicated)

 administer prescribed medications, typically epinephrine, corticosteroid, and diphenhydramine

9. monitor side effects of radiation therapy and treat as indicated

o follow radiation safety protocol for implanted, sealed radiation source o local skin changes

 gently wash irradiated area with warm water (with or without mild soap); use hand, not washcloth

 take care not to remove skin markings o alopecia

o fatigue - most common side effect of radiation (see side effects of chemotherapy on previous page)

o altered sense of taste (see side effects of chemotherapy on previous page)

10. monitor for complications of bone marrow transplantation (see also Infection Precautions for Bone Marrow Transplant Recipients)

o failure to engraft

o graft-versus-host disease in allogeneic transplants - (cautiously) managed with immunosuppressive agents

o veno-occlusive disease - treat with fluids and supportive therapy 11. support client and family

o listen to and discuss expected body image changes

o respect client lifestyle choices, religious and cultural preferences o discuss potential effect of (irreversible) infertility

o discuss end-of-life and grief and loss issues o initiate appropriate support and resource systems o

CANCER Interventions: C =Comfort

A =Altered body image N =Nutrition

C =Chemotherapy

E =Evaluate response to medications R =Respite for caretakers

2. Cancer Pain Management o Causes of cancer pain

 bone destruction  obstruction of an organ

 compression of peripheral nerves  infiltration or distention of tissue  inflammation

 necrosis

 psychological factors, e.g., fear, anxiety

o Use a variety of pain relief measures (see Lesson 5: Basic Care and Comfort for information regarding non-pharmacologic pain relief measures)

o The World Health Organization has developed a 3-tiered approach for treating cancer pain

 begin with nonopioid analgesics (aspirin, paracetamol) if pain occurs

 if pain persists or increases, administer mild opioids (codeine) for mild to moderate pain, along with adjuvant medications to calm fears and anxiety

 strong opioids (morphine) should be administered if pain is still not relieved, along with adjuvant medications to calm fears and anxiety o Nursing care, related to pain

 assess client's pain; pain is what the client describes - do NOT under-medicate the cancer client who is in pain!

 monitor effectiveness of medication

 monitor for side effects of medication, e.g., respiratory depression related to narcotic administration

 provide nonpharmacological techniques for pain relief, e.g., guided imagery, biofeedback, massage, heat-cold applications, relaxation techniques



Refer to the World Health Organization's Pain Ladder for cancer pain relief.

2. Pediatric Oncology

 Sudden tendency to bruise  Rapid, unexplained weight loss  Change in vision or eye

 Recurrent fever

 Persistent headache, often with vomiting  Change in balance or gait

 Childhood cancers can occur suddenly, without early symptoms  Childhood cancers usually arise from noninherited mutations in genes

of growing cells

 There are 12 major types of childhood cancers; leukemias and cancers of the brain and central nervous system account for more than half of the new cases

 Childhood cancer is highly curable

 For all age children, the goal is to prevent fear and misunderstanding

Age appropriate diversional activities:

Toddler washable soft toys, appropriate cartoons, action toys (wagon, push toys)

Pre-school appropriate cartoons, washable stuffed doll, coloring books and crayons, action toys

Age appropriate diversional activities:

toys

School age appropriate cartoons or video games, coloring book and crayons, school work when appropriate, computer, beads for creating jewelry

Middle School

computer or cell phone, appropriate video games, school work when appropriate

High School computer or cell phone, appropriate video games, school work when appropriate

2. Leukemias

o Definition: cancer of while blood cells

o Etiology

 unrestricted proliferation of immature leukocytes crowd the bone marrow and flood the bloodstream; this interferes with production of red blood cells and platelets, resulting in anemia and bleeding problems and increased risk of infection

 account for 25% of all childhood cancers

 types: most common is acute (rapidly developing); also chronic (slow developing)

 acute (rapidly developing) - most common

 acute lymphocytic leukemia (ALL) - usually found in children ages 2 to 8 years

 acute myelogenous leukemia (AML)  chronic (slow developing)

 risks: associated with having received prior radiation or chemotherapy for other types of cancer, genetic disorders (Down syndrome,

 symptoms caused by infiltration and replacement of any tissue of the body with non-functional leukemia cells

 highly vascular organs such as spleen and liver are most severely affected

o Findings: acute or insidious onset depending on type  anemia, thrombocytopenia, infection, bleeding

 lymphadenopathy, hepatosplenomegaly, bone or joint pain  meningeal irritation, i.e., irritable, lethargic, stiff neck o Diagnostics

 history and physical findings  peripheral blood smear  bone marrow aspiration  lumbar puncture

o Management

 combination chemotherapy to achieve a remission; intrathecal administration of methotrexate

 radiation with central nervous system involvement  bone marrow transplant

o Nursing interventions

 prepare child and family for diagnostic procedures  relieve discomfort

 monitor for infection, hemorrhage and anemia

 manage problems of drug side effects, i.e., nausea and vomiting, anorexia, mucosal ulceration, neuropathy, alopecia, moon face  provide nutritional snacks

 refer for needed services - financial or home care  teaching points

 long term treatment plan  multidisciplinary approach

 bone marrow aspiration precautions

 encourage parents to ask questions when unsure  school work for child when appropriate



Children, particularly toddlers and pre-schoolers, tend to have bruises as a result of play. Any unusual bruising -on the back or neck, large or dark bruises- needs to be checked out. It could be the first sign of leukemia or it could possibly due to child abuse. If you are unsure, be sure that another nurse checks the child with you.

3. Hodgkin's disease (Hodgkin's lymphoma)

o Definition: malignancy of the lymph tissue found in the lymph nodes, spleen, liver, and bone marrow

o Etiology

 neoplasm of lymphatic system

 characterized by giant, multinucleated cells (Reed-Sternberg cells) o Findings

 characterized by painless enlargement of lymph nodes, particularly in supraclavicular area

 anorexia, weight loss, malaise; painless; night sweats  fever

o Diagnostics

 lymphangiography

 labs: complete blood count (CBC), erythrocyte sedimentation rate, urinalysis, kidney function tests, protein levels, liver function tests  bone marrow biopsy

 CT scan of the chest, abdomen, pelvis  chest x-ray

 PET scan o Management

 chemotherapy and radiation

 treatment based on staging of disease (stages I-IV) and age of client  transfusion of blood products (platelets for low platelet counts or

packed cells for anemia)  antibiotics

o Nursing Interventions

 prepare for diagnostic procedures  explain side effects of treatment

 provide age appropriate diversional activities

 refer to appropriate resources if sterility may result from radiation and/or chemotherapy

 teaching points

 long term treatment plan  multidisciplinary approach

 encourage to ask questions when unsure  school work for child when appropriate o Possible Complications

 prognosis: most curable form of cancer

 long term complications of chemotherapy or radiation therapy 4. Neuroblastoma

o Definition: malignant tumor the develops from nerve tissue o Etiology: unknown

 most common extracranial solid tumor of childhood  accounts for almost all cases of cancer under age 1 year

 develops from tissues that form the sympathetic nervous system

 most neuroblastomas begin in the abdomen (in the adrenal gland or next to the spinal cord) or in the chest - can spread to the bones, bone marrow, liver, lymph nodes, skin and around the eyes

 often has metastasized by the time it is diagnosed

o Findings: first symptoms are usually fever, malaise and pain; other findings are tumor-dependent

 enlarged abdomen - from tumor or excess fluid  periorbital edema, cyanosis - cancer spread to eye(s)  bone pain or tenderness - cancer spread to bones  dyspnea or chronic cough - cancer spread to lungs/chest  flushed red skin

 tachycardia  profuse sweating o Diagnostics

 physical exam - examination of abdomen may reveal a lump, swollen lymph nodes

 bone scan, x-rays

 CT and MRI scan of chest and abdomen  biopsy

 labs: complete blood count (anemia), coagulation studies (ESR), hormone tests (especially epinephrine and other catecholamines), 24-hour urine (for catecholamines, homovanillic acid and vanillylmandelic acid) o Management: depends on tumor location, metastasis and client's age

 ranges from observation only in certain types of neuroblastoma to aggressive therapy with surgery, radiation therapy, chemotherapy, and stem-cell

transplantation for older children

 retinoid therapy, tumor vaccines and immunotherapy (using monoclonal antibodies)

o Nursing intervention: support family and encourage participation in support groups and counseling

o Complications

 prognosis: varies greatly

 metastasis and associated damage and loss of function of involved organ(s)  children treated for neuroblastoma may be at risk for getting a second,

different cancer in the future 5. Osteosarcoma

o Definition: malignant bone tumor that usually develops during a period of rapid growth (adolescence, young adulthood)

o Etiology: unknown

 usually affects teens and people in their 20s  originates from bone-forming mesenchyme

 location - most common in distal femur, also in the tibia or humerus  may be a genetic link (gene associated with retinoblastoma) o Findings: localized pain, limp, decrease in physical activity

o Diagnostics

 history, physical assessment  bone scans, x-ray

 chest x-ray, CT scan of the chest - for suspected metastasis to chest o Management

 surgery - limb salvage with prosthetic bone replacement or amputation  chemotherapy before and/or after surgery

o Nursing interventions

 client and family support following amputation  client and family teaching about stump care

 referral to necessary resources for prosthetics, rehabilitation, support and counseling

o Complications

 prognosis: long-term survival is good if cancer has not spread to lungs  limb removal

 metastasis

 side effects of chemotherapy 6. Ewing sarcoma

o Definition: a rare malignant bone tumor affecting children o Etiology: unknown

 arises not from osteoid tissue but in bone marrow spaces  most common in shaft of femur, tibia, humerus, scapula  more common in males and Caucasian children

 can occur any time but usually develops during puberty o Findings

 few symptoms

 localized pain, decrease in physical activity  pathologic fracture at site of the tumor o Diagnostics

 biopsy, MRI, x-ray of tumor  bone scan

 chest x-ray, CT of chest o Management

 intensive radiation therapy of the malignant bone  combined with chemotherapy

 cyclophosphamide (Cytoxan)  doxorubicin (Adriamycin)  etoposide (Vepesid)  ifosfamide (Ifex)  vincristine

 after course of chemotherapy and possibly radiation, tumors may be removed surgically; amputation may be the only choice

o Nursing interventions

 assess client's and family's physical and emotional status  client and family education

 encourage participation in support groups and counseling

 provide nursing care for client undergoing chemotherapy and radiation therapy

o Complications

 treatments have many complications and should be discussed on individual basis

7. Wilms' tumor (nephroblastoma)

o Definition: a rare type of kidney cancer that affects children o Etiology

 causes a tumor on one or both kidneys (more common on left kidney)  most often affects children under age 5 years

 risks: certain genetic conditions or birth defects (hypospadias, undescended testicles, aniridia); family history; female; African American

 tumor encapsulated for extended period o Findings

 abdominal mass and swelling  characteristically firm, non-tender  constipation

 malaise

 high blood pressure

 increased growth on one side of body

o Diagnostics

 abdominal ultrasound, x-ray  intravenous pyelogram  bone scans

 labs: blood urea nitrogen, complete blood count (may show anemia), creatinine and creatinine clearance, urinalysis

 do NOT prod or push on child's belly o Management

 surgery - simple nephrectomy, partial nephrectomy, radical nephrectomy  combination chemotherapy and radiation therapy

o Nursing interventions

 use care during bathing and handling to avoid injury to tumor site  support family

 treat effects of radiation and chemotherapy - nausea and vomiting, loss of appetite, mouth sores, fatigue, loss of hair, weakened immune system  teaching - tell parents to check with health care provider before any

vaccinations o Complications

 prognosis: 90% cure rate if tumor has not spread  hypertension

 kidney damage 8. Rhabdomyosarcoma

o Definition: a malignant tumor of the muscles attached to bones; the most common soft tissue tumor in children

o Etiology: unknown

 soft tissue neoplasm

 grows from undifferentiated mesenchymal cells of skeletal muscle

 location: most common in head and neck, the urogenital tract, arms or legs  may be a genetic factor

 highly malignant; often metastasized when diagnosed o Findings

 non-tender, firm mass

 related to site of tumor and compression of adjacent organs  symptoms often vague, similar to otitis media or "runny nose" o Management: depends on the site and type of rhabdomyosarcoma

 surgery

 high-dose irradiation of the primary tumor  combination chemotherapy

 surgical resection o Nursing intervention

 pain management, including administration of pain medication, positioning, age-appropriate diversional activities

 encourage family participation in support group and counseling o Complications

 prognosis: usually good

 complications from chemotherapy  metastasis

9. Retinoblastoma

o Definition: a rare, cancerous tumor of the retina o Etiology:

 caused by a mutation in a gene controlling cell division  may have a genetic link

 generally affects children under the age of 6 years o Findings:

 may affect one or both eyes  differing iris colors in each eye

 leukocoria ("cat's eye reflex") - unusual whiteness noticeable in photographs taken with a flash

 strabismus, poor vision, double vision  eye pain and redness

o Diagnostics

 ophthalmoscopic exam under general anesthesia,  MRI and CT scan of the head

 head and eye echoencephalogram (ultrasound of the eye) o Management: treatment depends on stage of tumor with grading

 radiation therapy - local tumor or larger tumors

 chemotherapy - if tumor has spread beyond the eye(s)  enucleation

o Nursing interventions

 assess child for this when parents report a strange light in the child's eye  involve parents in care and teach about diagnostic procedures

 genetic counseling for parents

 multi-disciplinary support for child following enucleation of an eye  teaching points: care for prosthetic eye

o Complications

 prognosis: if the cancer has not spread beyond the eye, almost all clients can be cured

 blindness

10.

Circulatory System Oncology

 Definition: cancer of the lymphocytes found in lymphoid tissue, which includes lymph nodes, spleen, and other organs of the immune system  Etiology: unknown

 both B lymphocytes and T lymphocytes can develop into lymphoma cells (B-cell lymphomas are more common in the U.S.)

 risk factors: adults with weakened immune systems or who have had an organ transplant

 types: based on how fast it spreads and by protein (B lymphocytes) and/or genetic markers (T lymphocytes)

 slightly more common in women

 Findings: many are dependent upon the location of the cancer (chest, abdomen, brain)

 painless, enlarged lymph nodes in cervical or axillary region  night sweats, fever

 itching  weight loss  Diagnostics

 physical exam - enlarged lymph nodes

 biopsy of suspected tissue (usually lymph node)  bone marrow biopsy

 labs: complete blood count, protein levels, liver function, kidney function and uric acid level

 Management: depends on type of lymphoma, stage of the cancer, age and overall health of client, symptoms

 chemotherapy - main type of treatment

 radiation - for disease confined to one body area  radioimmunotherapy may be used

 bone marrow transplant (using client's stem cells) - when chemotherapy is ineffective or lymphoma returns

 immunologic therapy: rituximab (Rituxan), a monoclonal antibody  Nursing interventions - see Oncology Overview for more specifics

 encourage participation in support group and/or counseling

 client teaching: oral care, preventing infections during chemotherapy; self care of central line or PICC line; diet

 Complications

 prognosis: dependent on 5 factors - client's age, stage of lymphoma, organs affected outside the lymph system, ability to perform ADLs,

serum level of lactate dehydrogenase (which goes up with amount of lymphoma in the body)

 autoimmune hemolytic anemia  infection

 side effects of chemotherapy drugs

11.

Respiratory System Oncology

o Cancer of the larynx  Etiology

 most tumors of the larynx are squamous cell carcinoma  more common among men, age 50 to 65 years-old

 risk factors include cigarette smoking and alcohol consumption  Findings

 persistent sore throat  dyspnea

 dysphagia

 increasing persistent hoarseness  weight loss

 enlarged cervical lymph nodes  neck pain/lump in neck (late)  Diagnostics

 physical exam - may detect lump on outside aspect of neck

 other tests: biopsy, chest x-ray, CT scan of chest, head and/or neck, MRI of head or neck

 Management

 either surgery or radiation therapy alone - when tumor is small  chemotherapy, along with radiation - when tumor is larger or has

spread to lymph nodes

 surgery: removal of all or part of larynx (laryngectomy)  brachytherapy

 Nursing interventions - see Oncology Overview for more specifics  arrange for clients with laryngectomies to meet with members of

support groups

 establish a method for communication before surgery to use after surgery

 maintain airway; have suction equipment at bedside  observe for signs of hemorrhage or infection

 teach about tracheostomy and stoma care  assist with period of grieving

 coordinate nutritional support  Complications

 prognosis: throat cancers can be cured in 90% of clients if detected early

 possible airway obstruction  difficulty swallowing

 disfigurement of the neck or face  loss of voice and speaking ability  metastasis

Watch a video from MedlinePlus about cancer of the larynx.

Institute.

Refer to the National Cancer Institute's book Eating Hints: Before, During and After Cancer Treatment

2. Lung cancer o Etiology

 types of lung cancer

 squamous cell carcinoma  small-cell (oat cell) carcinoma  adenocarcinoma

 large cell carcinoma  prognosis is generally poor

 largely preventable if smokers stop and nonsmokers avoid second hand smoke

o Findings

 hoarse voice

 changes in breathing

 persistent cough or change in cough  blood-streaked or bloody sputum  chest pain or tightness in chest wall  recurring pneumonia, pleural effusion  weight loss

o Diagnostics

 medical imaging examinations

 cytological sputum analysis, carcinoembryonic antigen (CEA) test, complete blood count, liver and kidney function tests

 bronchoscopy  biopsy

3. Management o nonsurgical

 adjuvant therapy: chemotherapy and radiation therapy

 biological therapies, including monoclonal antibodies (especially

angiogenesis inhibitors), interferons, interleukins, colony-stimulating factors, vaccines, gene therapy and nonspecific immunomodulating agents

 laser therapy to de-bulk tumor  thoracentesis and pleurodesis o surgical: thoracotomy

 wedge resection - part of a lobe  segmental resection- part of a lobe  lobectomy - one or more lobes

 pneumonectomy - entire right or left lung

4. Nursing interventions - see Oncology Overview for more specifics o maintain chest drainage system

o provide routine post operative care

 monitor respiratory status frequently

 teach effective deep breathing and cough techniques

 refer to physical therapy for exercises for shoulder on affected side  relieve pain

o optimize oxygenation

o provide opportunities for the client to talk about cancer; as needed, refer to support groups

o teach information as based on treatment plan and prognosis o optimize nutritional status

o

Health care professionals and clients can access comprehensive educational materials on cancer and chemotherapy at Medline Plus.

5. Neurological System Oncology

 Definition: growth of tissue within skull  may be cancerous or benign  classified according to tissue type  may be primary or metastatic

 Findings

 increased intracranial pressure  depend on size and location of tumor

 frontal lobe: personality changes, focal seizures, visual disturbances, hemiparesis, aphasia

 occipital lobe: focal seizures, visual hallucinations  temporal lobe: seizures, headache

 parietal lobe: seizures, visual losses

 cerebellum: coordination or walking/mobility difficulties 6. Diagnostics

o history and physical exam

o computerized tomogram (CT) scan o magnetic resonance imaging (MRI) 7. Management

o goals are to remove the tumor and minimize harm to the nervous system o depends on location and size of tumor

o treatment for increased intracranial pressure  surgery

 craniotomy to remove tumor  stereotactic laser surgery  radiation therapy for malignancy

o pharmacologic: chemotherapy (for malignant tumors) 8. Nursing interventions - see Oncology Overview for more specifics

o care of the client with increased intracranial pressure o care of the client undergoing surgery

o seizure precautions o seizure care

o good nutrition and fluid balance o emotional support

o care of the client undergoing chemotherapy

9. Gastrointestinal

o Colon cancer

 Definition: the development of malignant cells in the epithelium of the large intestine

 Etiology

 may develop from adenomatous polyps

 risk factors: low residue diet, high-fat diet, refined foods, age over 50 years, history of polyps of the colon and/or rectum, family history, inflammatory bowel disease, exposure to carcinogens

 Pathophysiology

 adenocarcinoma is the most common type

 most common locations are sigmoid rectum and ascending colon  often metastasizes to the liver

 Findings

 rectal bleeding

 change in bowel habits - constipation, diarrhea  change in shape of stool

 anorexia and weight loss  abdominal pain, palpable mass



Visit the American Gastroenterological Association patient center for more information on colorectal cancer and screenings.

o colonoscopy o sigmoidoscopy o digital examination

o stool for occult blood, complete blood count, liver function tests, carcinoembryonic antigen (CEA) test

o barium enema o CT scan

o carcinoembryonic antigen (CEA)

6. Complications - obstruction, perforation of the bowel wall by the tumor, metastasis 7. Management

o radiation

o chemotherapy

o local excision and fulguration (small, localized polypoid lesions) o treatment of choice is surgery - bowel resection, colostomy

 right hemicolectomy - involves ascending colon  left hemicolectomy - involves descending colon

 abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy

8. Nursing interventions - see Oncology Overview for more specifics o manage pain

o monitor for complications  wound infection  atelectasis  thrombophlebitis

o maintain fluid and electrolyte balance o care of ostomy

9. Liver Cancer (hepatocellular carcinoma) o Definition: cancer of the liver o Etiology

 the cause of liver cancer is usually scarring of the liver (cirrhosis), due to alcohol abuse, hepatitis B or C virus infection, autoimmune diseases of the liver, hemochromatosis

 occurs more often in men

 usually seen in people older than age 50 o Findings

 abdominal pain or tenderness (upper right quadrant)  easy bruising or bleeding

 enlarged abdomen  fatigue

 jaundice o Diagnostics

 abdominal CT scan, ultrasound, MRI  liver biopsy

 laparoscopy

 chest x-ray - to determine if the liver tumor is primary or has metastasized from a primary tumor in the lungs

 liver enzymes, serum alpha fetoprotein, serum bilirubin o Management

 surgery or liver transplant - best for treating small or slow-growing tumors  chemotherapy

 radiation treatments

 sorafenib tosylate (Nexavar): blocks tumor growth  prevention: childhood vaccination against hepatitis B  immunosuppressive drugs - following liver transplant

1. tacrolimus (Hecoria, Prograf) 2. cyclosporine (Neoral, Gengraf) 3. sirolimus (Rapamune)

4. mycophenolate mofetil (MMF) (Cellcept) 5. corticosteroids

6. azathioprine (Imuran)

7. muromonab-CD3 or OKT3 (Orthoclone) 8. thymoglobulin (Anti-Thymocyte Globulin) 9. IL-2 Receptor Antagonist Antibodies 10. Nursing interventions - see Oncology Overview for more specifics

o encourage participation in support groups

o encourage discussion of end-of-life wishes and efforts to improve quality of life o overview of post op care following liver transplant

 respiratory status - care of client on ventilator  care for intravenous lines (peripheral and arterial)

 care for drains/tubes, including Jackson-Pratt, T-tube, nasogastric, Foley  have emergency equipment nearby, e.g., crash cart, Level 1 rapid infuser  monitor neurologic status

 renal status - monitor BUN, creatinine; also intake and output

 integumentary status - care for incision/dressing (abdominal binder may be used), care for pruritus with topical lotions, position to reduce risk of skin breakdown

 gastrointestinal status

1. assess for ileus, re-bleeding from preexisting varices, diarrhea, signs of acute abdomen

 monitor for signs of infection and rejection (which may occur simultaneously) - fever, decreased quantity/quality of bile, change in liver function test results, malaise, increased ascites

o care for end stage liver disease (ESLD)

 monitor labs - fluid and electrolyte imbalances, platelet counts, serum ammonia

 low protein diet

 assist with ambulation, range of motion due to muscle weakness, stiffness  monitor for bleeding, stool for occult blood, hemoglobin and hematocrit  monitor breathing and elevate head of bed

 monitor intake and output

 monitor for encephalopathy - neurologic signs  monitor for indications of renal failure

 monitor skin for breakdown and apply lotion - pruritus is common

 administer diuretics for ascites and care for client undergoing paracentesis  monitor and treat nausea and vomiting

 prevent or manage constipation  assist with pain management 11. Complications

o poor prognosis

o gastrointestinal bleeding, liver failure, metastasis to other parts of the body 12. Pancreatic Cancer

o Definition: cancer of the pancreas o Etiology: unknown

 more common in people with diabetes, chronic pancreatitis, smokers  may be genetic link

o Findings

 dark urine and clay-colored stools  fatigue and weakness

 jaundice

 loss of appetite and weight loss  nausea and vomiting

 abdominal pain or discomfort (right upper quadrant) o Diagnostics

 CT and MRI of the abdomen

 endoscopic retrograde cholangiopancreatography (ERCP)  endoscopic ultrasound

 pancreatic biopsy

 labs: complete blood count, liver function tests, serum bilirubin, carcinoembryonic antigen (CEA) test

o Management

 surgery - pancreaticoduodenectomy (Whipple procedure)

1. may be done but usually cancer is so advanced that surgery is often not successful

2. involves removing the head of the pancreas, gallbladder, part of the duodenum, the pylorus, the lymph nodes near the head of the pancreas

 radiation therapy or chemotherapy - when the tumor has not spread out of the pancreas but cannot be removed

o Nursing interventions - see Oncology Overview for more specifics  pain management

 manage complications of Whipple procedure - delayed gastric emptying and other digestive difficulties

o Complications

 very poor prognosis

 common complications: blood clots, depression, infection, liver problems, pain, weight loss

13.

Genitourinary System Oncology

 Definition: cancer that starts in the bladder (from the transitional cells lining the bladder)

 Etiology: unknown

1. classified on the way the tumor grows

1. papillary tumors: wart-like appearance and are attached to a stalk

2. nonpapillary (sessile) tumors: flat, less common, more invasive and worst prognosis

2. possible causes: cigarette smoking, chemical exposure (at work), chemotherapy, radiation treatment, chronic bladder infection or irritation

 Findings

1. abdominal pain 2. blood in the urine

3. bone pain or tenderness (due to metastasis)

4. urination - painful, frequency, urgency, incontinence 5. weight loss

 Diagnostics

1. abdominal and/or pelvic CT, MRI 2. bladder biopsy

3. cystoscopy

4. intravenous pyelogram

5. urinalysis and urine cytology  Management

1. stage 0 and I

1. surgery to remove the tumor without removing the bladder - usually a transurethral resection of the bladder (TURB) 2. chemotherapy

3. immunotherapy: usually the Bacille Calmette-Guerin vaccine (BCG) or interferon given directly into the bladder using a Foley catheter

2. stage II and III

1. surgery to remove part of or entire bladder 1. cystectomy - remove bladder

2. ileal conduit, continent urinary reservoir, or orthotopic neobladder surgery may be performed to help drain urine after the bladder is removed

2. chemotherapy and radiation therapy either before (to shrink tumor) and/or after surgery

3. stage IV

1. no surgery

2. chemotherapy may be considered - inserting agents doxorubicin HCl (Adriamycin PFS), valrubicin (Valstar) and epirubicin (Ellence)

3. palliative care 4. laser-ablation therapy

 Nursing interventions - see Oncology Overview for more specifics 1. palliative care

2. encourage participation in support groups and counseling

3. support change in body image following urinary diversion surgery 4. support clients with changes to their sexuality

 Complications

1. prognosis depends on the stage of cancer 2. anemia

3. urinary incontinence 4. urethral stricture

14.

Endocrine System Oncology

 Etiology

1. radiation exposure increases risk for thyroid malignancies 2. thyroid malignancy is rare in the U.S. (benign thyroid disease is

relatively common)

3. most thyroid tumors are benign

4. most common types: papillary and follicular

5. greater likelihood of malignancy in clients older than age 60 years and younger than 30 years-old

 Findings: painless, palpable, solitary nodule on thyroid gland  Diagnostics

1. history and physical (palpation of nodule) 2. fine needle aspiration biopsy (FNAB) 3. ultrasound of the thyroid, thyroid scan 4. laryngoscopy

5. serum thyroid-stimulating hormone (low), calcitonin  Management

1. surgical excision - total or subtotal thyroidectomy 2. postoperative radioiodine scanning and ablation

3. RapidArc radiotherapy: a fast and precise form of radiation therapy 4. possibly chemotherapy

5. medications

1. thyroid hormone replacement therapy - usually T4 (Synthroid) or triiodothyronine (T3, Cytomel)

2. recombinant human TSH (Thyrogen) - in remnant ablation  Nursing interventions - see Oncology Overview for more specifics

1. support clients undergoing radioisotope treatment

2. post-operative care: relieve pain, observe for indications of tracheal obstruction, swelling, bleeding or laryngeal spasm

 Complications

1. injury to the larynx and hoarseness after thyroid surgery

2. low calcium levels from accidental removal of parathyroid glands 3. metastasis

15.

Integumentary System Oncology

 Definition: malignant tumors that originate in the pigment-producing melanocytes in the basal layer of the epidermis

 Etiology

1. fair skin, blue or green eyes, or red or blond hair 2. live in sunny climates or at high altitudes

3. have had one or more blistering sunburns during childhood 4. use tanning devices

5. genetic predisposition

 Findings - identification of potentially malignant pigmented lesions 1. A for asymmetry

2. B for border irregularity 3. C for color multiplicity

4. D for diameter greater than 1/4 inch

5. E for evolution (change) in size and/or shape  Diagnostics

1. epiluminescence microscopy (magnification and polarized light to enhance detection)

2. biopsy

3. sentinel lymph node biopsy - to predict progression of disease 16. Nonmelanoma skin cancers - account for more than 90% of skin cancers

o Basal cell carcinoma (BCC)

 definition: abnormal, uncontrolled growths or lesions from the skin's basal cells (the deepest layer of the epidermis)

1. usually caused by a combination of cumulative UV exposure and intense, occasional UV exposure

2. almost never metastasizes 3. most common form of skin cancer

 finding: look like open sores, red patches, pink growths, shiny bumps, or scars

 management

1. surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation, cryosurgery, photodynamic therapy, laser surgery

2. radiation

3. topical medications

1. imiquimod (Aldara) - for superficial BCC; works by stimulating the immune system

2. 5-Fluorouracil (5-FU) - for superficial BCC 3. vismodegib (Erivedge) - for more advanced BCC

Black Box Warning - embryotoxic and teratogenic  nursing interventions

1. teaching about skin cancer prevention and identification 2. supportive care for disfigurement

17. Squamous cell carcinoma

o definition: uncontrolled growth of abnormal cells arising in the squamous cells (upper layers of the epidermis)

o etiology

 second most common form of skin cancer

 mainly caused by cumulative UV exposure over the course of a lifetime  can be disfiguring and may be deadly if allowed to grow

o findings

 look like scaly red patches, open sores, elevated growths with central depression, or warts; may crust or bleed

 usually occurs on any area exposed to sun but may occur on mucous membranes and genitals

o management

 surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation, cryosurgery, photodynamic therapy, laser surgery  radiation

 topical medications: 5-Fluorouracil (5-FU) o nursing interventions

 teaching about skin cancer prevention and identification  supportive care for disfigurement

18. Actinic keratosis (also called solar keratoses): scaly or crusty growths (lesions) caused by damage from UV light; the most common pre-cancer

19. Dysplastic nevi (atypical moles): unusual benign moles that resemble melanoma 20. Breast cancer

o definition: cancer that starts in the tissues of the breast types of breast cancer o etiology

 in women, may begin in lining of milk duct or the lobes  higher risk if family history

 risk may increase with the use of hormones  types

1. invasive (infiltrating): spreading outside the membrane that lines a duct or lobule, invading the surrounding tissues

2. noninvasive (in situ) - includes ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS)

o findings

 painless, firm lump - most often immoveable  painless thickening in a breast

 enlargement of axillary nodes or supraclavicular nodes  nipple discharge

 scaliness or retraction of nipple (seen more in Paget's disease)  pain, ulceration, edema, orange-peel skin (usually late finding) 

See pictures of the types of breast cancer at Breastcancer.org.

4. diagnostics

o biopsy or aspiration (stereotactic biopsy, Mammotome® or vacuum-assisted biopsy, ultrasound-guided biopsy, ductal lavage)

o tumor cell tests

o tests to determine metastases (bone scan, MRI, CT scan)

o labs: tumor marker tests, including carcinoembryonic antigen (CEA) test, CA15.3, TRU-QUANT, CA125

5. management

o surgical approach (will depend on the results from the lymph node biopsies and tumor staging) - from most conservative to radical

1. lumpectomy - tumor removal and small amount of normal tissue around it 2. partial mastectomy - removal of part of breast with cancer and some

surrounding tissue

3. total mastectomy - removal of whole breast

4. modified radical mastectomy - removal of whole breast, many of the lymph nodes, the lining over the chest muscles

5. radical mastectomy - removal of whole breast, all of the lymph nodes, chest wall muscles o radiation therapy o chemotherapy 1. cyclophosphamide (Cytoxan) 2. methotrexate (Mexate) 3. doxorubicin HCL (Adriamycin) 4. paclitaxel (Taxol) o endocrine therapy

1. bone marrow transplant 2. oophorectomy

3. adrenalectomy o hormone therapy

1. tamoxifen (Nolvadex): for premenopausal women with positive nodes or stage 1 with negative nodes

1. to block the effects of estrogen

2. the course of treatment is commonly a minimum of two years; may continue with tamoxifen or started with exemestane (Aromasin) or raloxifene (Evista) for 3 more years depending on hormonal levels in the breast

2. exemestane (Aromasin) or raloxifene (Evista): for post menopausal women 3. use of other hormones in advanced disease

1. estrogens (DES) or ethinyl estradiol (Estinyl) to suppress FSH and LH

2. progestins may decrease estrogen receptors

3. androgens may suppress FSH and estrogen production

4. aminoglutethimide blocks estrogen by blocking adrenal steroids 5. corticosteroids from the adrenal glands suppress secretion of

estrogen and progesterone 6. complications of breast cancer

o metastases

o bone pain, neurologic changes, weight loss, anemia

o shortness of breath, cough, pleuritic pain, nonspecific chest discomfort 7. nursing interventions - see Oncology Overview for more specifics

o obtain a health history

o identify the type of education needed o evaluate the level of anxiety and fear o determine the levels of coping abilities o refer available support systems to

1. reduce anxiety 2. provide education

3. enhance coping strategies

o assess for lymphedema and nerve damage following a radical or modified radical mastectomy (when lymph nodes are removed)

o

Learn more about breast cancer from The National Breast Cancer Foundation.

Breastcancer.org provides complete, accurate, and private information about breast cancer.

4. Male oncology

o Breast cancer in males

 cancer resembles the types found in women  a greater incidence in men in their 60's

 accounts for about 1% of all breast cancer cases

 prognosis is poor because men delay seeking diagnosis and treatment

2. Prostate cancer

o definition: malignant neoplasm, usually adenocarcinoma, of prostate gland o etiology and epidemiology

 more prevalent in African American men

 most appear on the peripheral zone of the gland  most are palpable on rectal examination

 spreads via the lymphatics, the bloodstream or by local extension  specific etiology unknown; familial history increases risk

o findings

 usually asymptomatic in early stages

 obstruction of urinary flow that may result in urinary urgency, hesitancy, dribbling, retention, nocturia, infection, hematuria

 pain in an area represents the location of the metastases  lumbosacral  hips  lower legs  rectal discomfort  weight loss  anemia

 edema of the lower extremities o diagnostics

 digital rectal examination  needle biopsy of the gland  transrectal ultrasonography  descending urography  serologic markers

 prostate specific antigen (PSA)  prostatic acid phosphatase  metastatic evaluations

 intravenous urography (also called intravenous pyelography or IVP)

 CT scan of specific areas or entire body  MRI

3. management

o conservative approach

 usually no treatment for men over 70 due to the prostate cancer's slow progression

 analgesics to manage pain - both non-narcotic and narcotic  short course of radiation therapy (site-specific)

 administration of IV strontium chloride 89 (beta emitter agent)

 placement of suprapubic catheter for obstructed outflow through urinary tract

o surgical approach

 radical prostatectomy

 laparoscopic dissection of pelvic lymph node  cryosurgery

 transurethral resection of prostate (TURP) o curative approach

 external beam radiation

 interstitial radiation - the direct implantation of radioactive substances into the prostate either permanently (seeding) or briefly (high dose rate); also called brachytherapy, seed implantation

o palliative approach

 hormone manipulation

 estrogen therapy diethylstilbestrol (DES)  luteinizing hormone-releasing hormone (LHRH)  bilateral orchiectomy (removal of the testes)

 flutamide (Eulexin) - blocks the effect of testosterone  drugs are often used in combination therapy

4. nursing interventions - see Oncology Overview for more specifics o assess

 presence of urinary urgency, hesitancy, dribbling, retention, nocturia, infection, hematuria

 presence of palpable lymph nodes

 presence of flank pain, weight loss, rectal pain  presence of bladder distention

o control pain to acceptable levels

o reduce anxiety in clients and family members by referrals o discuss potential changes re: sexual functioning, energy levels 5. complications

o of the cancer - bone metastases o of hormone manipulation

 nausea and vomiting  gynecomastia  sexual dysfunction  hot flashes



UsTOO International is a prostate cancer support group whose goal is to increase awareness about the disease.

Points to Remember

Clients undergoing chemotherapy should avoid crowds and persons with infections and to report signs of infection.

Radiation has local effects related to site irradiated; chemotherapy is more systemic. Biological therapies (interferons, interleukins, colony-stimulating factors, monoclonal antibodies, vaccines, gene therapy, and nonspecific immunomodulating agents) use the body's immune system to fight cancer or to lessen the side effects that may be caused by some cancer treatments.

Although clients receiving internal radiation are not radioactive, the implant or injection is radioactive; treat waste products and body fluids as radioactive.

Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of cancer.

Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal antibodies, especially infliximab (Remicade), since they will allow TB to fulminate. Melanoma is the most dangerous form of skin cancer and the leading cause of death from skin disease.

Lung cancer is the leading cause of cancer deaths in both men and women

(exception - the leading cause of cancer deaths in Hispanic women is breast cancer). Most Pancreatic cancer has a very poor prognosis since it's often advanced when first discovered.

The cause of liver cancer is cirrhosis, which may occurs with hepatitis B or C. Individuals should be vaccinated for HBV. The Centers for Disease Control and Prevention recommends that all "baby boomers" are tested for HCV.

Administration of HPV vaccine Gardasil® is recommended for the prevention of cervical cancer.

Points to Remember - Pediatric

There are 12 major types of childhood cancers; leukemias and cancers of the brain and central nervous system account for more than half of the new cases.

Children typically have longer treatment plans than adults due to their increased metabolic rate and rate of cell turnover.

Cure rate is improving for most types of pediatric malignancies.

During nursing assessment of a child with Wilms' tumor, do NOT palpate the abdomen

Neuroblastoma is a cancer that actually begins in utero.

An active child who suddenly becomes lethargic and exhibits symptoms of childhood cancer, e.g., weight loss, pain, and fever, should be evaluated by a health care provider.

Acute leukemia can advance very quickly; a child with anemia and bruising should be evaluated for leukemia.

Osteosarcoma is more common than Ewing's sarcoma but both are tumors of the bone.

Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena cava syndrome, septic shock.

Pediatric cancer is a highly charged emotional arena. Be calm and collected in dealing with both parents and patients

All cancer victims and their families need support and encouragement. Families with children who have cancers can be especially affected. Other children in the family may need as much or more attention and support than the parents.