Download - NCM 104 Cellular aberration lecture 2007
UNDERSTANDINGCANCER
• Essential Concepts of Cancer– What is Cancer?– Normal Cell Growth vs. Cancer Cell
Growth– Etiology and Causative Factors– Pathophysiology– Classification of Tumors– Effects of Cancer
• Nursing Process– Assessment– Laboratory & Diagnostic Tests– Tumor Staging and Grading– Nursing Diagnoses & Planning– Implementation and Management
• Treatment Modalities– Chemotherapy
• End-of-life Issues
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What Is Cancer?
CANCER is a complex of diseases which occurs when normal cells mutate into
abnormal cells that take over normal tissue, eventually harming and destroying the host
WHAT IS CANCER• A large group of diseases
characterized by:– Uncontrolled growth and spread of
abnormal cells– Proliferation (rapid reproduction by cell
division)– Metastasis (spread or transfer of cancer
cells from one organ or part to another not directly connected)
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Loss of Normal Growth Control
Cancer cell division
Fourth orlater mutation
Third mutation
Second mutation
First mutation
Uncontrolled growth
Cell Suicide or Apoptosis
Cell damage—no repair
Normal cell division
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Oncogenes
Mutated/damaged oncogene
Oncogenes accelerate cell growth and division
Cancer cell
Normal cell Normal genes regulate cell growth
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Example of Normal Growth
Cell migration
Dermis
Dividing cells in basal layer
Dead cells shed from
outer surface
Epidermis
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The Beginning of Cancerous Growth
Underlying tissue
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Tumors (Neoplasms)
Underlying tissue
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Invasion and Metastasis
3Cancer cells reinvade and grow at new location
1Cancer cells invade surrounding tissues and blood vessels
2Cancer cells are transported by the circulatory system to distant sites
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• Viruses• Chemical carcinogens• Physical stressors• Hormonal factors• Genetic factors
ETIOLOGY/CAUSATIVE FACTORS
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What Causes Cancer?Some viruses or bacteria
HeredityDiet
Hormones
RadiationSome chemicals
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Population-Based Studies
CANADA:Leukemia
Regions of Highest Incidence
BRAZIL:Cervicalcancer
U.S.:Coloncancer
AUSTRALIA:Skincancer
CHINA:Livercancer
U.K.:Lungcancer
JAPAN:Stomachcancer
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Genes and Cancer
Chromosomes are DNA molecules
Heredity
RadiationChemicals
Viruses
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Viruses
Virus inserts and changes genes forcell growth
Cancer-linked virus
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Examples of Human Cancer Viruses
Some Viruses Associated with Human Cancers
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Bacteria and Stomach Cancer
H. pyloriPatient’s tissue sample
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Tobacco Use and CancerSome Cancer-Causing Chemicals in Tobacco Smoke
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High-Strength Radiation
Most
High
LowLeast
Leukemia Incidence
X-ray Dose(atomic radiation)
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AIDS and Kaposi’s Sarcoma
Kaposi’ssarcoma
Withoutdisease
Depressedimmunesystem
HIV infection
KSHV infection
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Heredity and Cancer
Inherited factor(s)
All Breast Cancer Patients
Other factor(s)
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Heredity Can Affect Many Types of Cancer
Inherited Conditions That Increase Risk for Cancer
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PATHOPHYSIOLOGYABNORMAL CELL FORMED BY MUTATION OF DNA
CELL GROWS AND PROLIFERATES
METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD
– Cancer development linked to immune system failure
– Example of clients susceptible to developing cancer
Classification of Cancer• According to Behavior of Tumor• Benign - tumors that cannot spread
by invasion or metastasis; hence, they only grow locally
• Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term “cancer” applies only to malignant tumors
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Malignant versus Benign Tumors
Malignant (cancer) cells invade neighboring tissues, enter blood vessels, and metastasize to different sites
Time
Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis
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Why Cancer Is Potentially Dangerous
Melanoma cells travel through bloodstream
Melanoma(initial tumor)
Brain
Liver
Patterns of cell Proliferation• Hyperplasia • Dysplasia• Metaplasia• Anaplasia
• Neoplasia
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Hyperplasia
HyperplasiaNormal
• tissue growth based on an excessive rate of cell division, leading to a larger than usual number of cells; the process of hyperplasia is potentially reversible; can be a normal tissue response to an irritating stimulus. An example is a callus
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Dysplasia
Hyperplasia Mild dysplasiaNormal
• Bizarre cell growth differing in size, shape and cell arrangement
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Carcinoma in Situ
Milddysplasia
Carcinoma in situ (severe dysplasia) Cancer
(invasive)
Normal Hyperplasia
Patterns of cell Proliferation• Metaplasia
• conversion of one type of cell in a tissue to another type not normal for that tissue
• Anaplasia • change in the DNA cell structure and
orientation to one another, characterized by loss of differentiation and a return to a more primitive form.
• Neoplasia• uncontrolled cell growth, either benign or
malignant
Metastasis• Metastasis: 3 stages
– Invasion – neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph.
– Spread – tumor cells spread through lymph or circulation or by direct expansion
– Establishment and growth – tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation
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Cancer Tends to Involve Multiple Mutations
Malignant cells invade neighboring tissues, enter blood vessels, and metastasize to different sites
More mutations, more genetic instability, metastatic disease
Proto-oncogenes mutate to oncogenes
Mutations inactivate DNA repair genes
Cells proliferate
Mutation inactivates suppressor gene
Benign tumor cells grow only locally and cannot spread by invasion or metastasis
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Mutations and Cancer
Genes Implicated in Cancer
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Cancer Tends toCorrupt Surrounding Environment
Growth factors = proliferation
Blood vessel
Proteases
Cytokines
Matrix
Fibroblasts, adipocytes
Invasive
Cytokines, proteases = migration & invasionBack
Classification of Tumors• CARCINOMAS: EPITHELIAL TISSUE
– BODY SURFACES, LINING OF BODY CAVITIES ETC: (ADENOCARCINOMA)
• SARCOMAS: CONNECTIVE TISSUE– STRIATED MUSCLE, BONE, ETC
(OSTEOSARCOMA)• LYMPHOMAS AND LEUKEMIAS
– HEMATOPOIETIC SYSTEM• NERVOUS TISSUE TUMORS
– EX. NERVE CELLS-NEUROBLASTOMA• MYELOMA
– Develops in the plasma cells of bone marrow
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Different Kinds of Cancer
Lung
Breast (women)
Colon
BladderProstate (men)
Some common sarcomas:Fat
Bone
Muscle
Lymphomas:Lymph nodes
Leukemias:Bloodstream
Some common carcinomas:
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Naming Cancers
Prefix Meaning
adeno- gland
chondro- cartilage
erythro- red blood cell
hemangio- blood vessels
hepato- liver
lipo- fat
lympho- lymphocyte
melano- pigment cell
myelo- bone marrow
myo- muscle
osteo- bone
Cancer Prefixes Point to Location
“ Women who smoke like men,
die like men.”
U.S. Surgeon General David Satcher
Women, Tobacco & Lung Cancer
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Effects of Cancer• Disruption of Function- can be due
to obstruction or pressure• Hematologic Alterations: can impair
function of blood cells• Hemorrhage: tumor erosion,
bleeding, severe anemia• Anorexia-Cachexia Syndrome:
wasted appearance of client
Effects of Cancer• Paraneoplastic Syndromes: ectopic
sites with excess hormone production– ↑ Parathyroid hormone→ hypercalcemia– ↑ secretion of insulin→ hypoglycemia– ↑ Antidiuretic hormone (ADH) → fluid
retention, HTN & peripheral edema
• ↑ Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, ↑ glucose levels)
Effects of Cancer• Pain: major concern of clients and
families associated with cancer• Physical Stress: body tries to
respond and destroy neoplasm• Psychological Stress
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ASSESSMENTASSESSMENT• Nursing History
– Health History – chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors)
– Cancer signs: CAUTION US!
• CAUTION US!– Change in bowel or bladder habits– A sore that does not heal– Unusual bleeding or discharge– Thickenings or lumps– Indigestion or difficulty in swallowing– Obvious change in a wart or mole– Nagging or persistent cough or hoarseness– Unexplained anemia– Sudden unexplained weight loss
Warning Signs of CancerWarning Signs of Cancer
• Change in bowel or bladder habits– A person with colon cancer may have
diarrhea or constipation, or he may notice that the stool has become smaller in diameter
– A person with bladder or kidney cancer may have urinary frequency and urgency
Warning Signs of Cancer
• A sore that does not heal– Small, scaly patches on the skin that
bleed or do not heal may be a sign of skin cancer
– A sore in the mouth that does not heal can indicate oral cancer
Warning Signs of Cancer
• Unusual bleeding or discharge– Blood in the stool is often the first sign
of colon cancer– Similarly, blood in the urine is usually
the first sign of bladder or kidney cancer– Postmenopausal bleeding (bleeding
after menopause) may be a sign of uterine cancer
Warning Signs of Cancer
• Thickenings or lumps– Enlargement of the lymph nodes or
glands (such as the thyroid gland) can be an early sign of cancer
– Breast and testicular cancers may also present as a lump
Warning Signs of Cancer
• Indigestion or difficulty in swallowing– Cancers of the digestive system,
including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing
Warning Signs of Cancer
• Obvious change in a wart or mole– Moles or other skin lesions that change
in shape, size, or color should be reported
Warning Signs of Cancer
• Nagging or persistent cough or hoarseness– Cancers of the respiratory tract,
including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice
Warning Signs of Cancer
Warning Signs of Cancer• Unexplained anemia
• Sudden unexplained weight loss
Physical AssessmentPhysical Assessment• Inspection – skin and mucus membranes
for lesions, bleeding, petechiae, and irritation– Assess stools, urine, sputum, vomitus for acute or
occult bleeding– Scalp noting hair texture and hair loss
• Palpation – Abdomen for any masses, bulges or abnormalities– Lymph nodes for enlargement
• Auscultation – of lung sounds, heart sounds and bowel sounds
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Laboratory & Diagnostic Laboratory & Diagnostic TestsTests
• Cancer detection examination• Laboratory tests
– Complete blood cell count (CBC)– Tumor markers – identify substance
(specific proteins) in the blood that are made by the tumor• PSA (Prostatic-specific antigen): prostate
cancer• CEA (Carcinoembryonic antigen): colon cancer• Alkaline Phosphatase: bone metastasis
– Biopsy
Diagnostic TestsDiagnostic Tests• Determine location of cancer:
– X-rays– Computed tomography– Ultrasounds– Magnetic resonance imaging– Nuclear imaging– Angiography
• Diagnosis of cell type:– ▪Tissue samples: from biopsies,
shedded cells (e.g. Papanicolaou (PAP) smear), & washings
– ▪ Cytologic Examination: tissue examined under microscope
• Direct Visualization:– ▪ Sigmoidoscopy– ▪ Cystoscopy– ▪ Endoscopy– ▪ Bronchoscopy– ▪ Exploratory surgery; lymph node
biopsies to determine metastases
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Cancer Detection and Diagnosis
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Early Cancer May Not Have Any Symptoms
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Cervical Cancer Screening
Abnormal Pap smear
Normal Pap smear
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Breast Cancer Screening
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Prostate and Ovarian Cancer Screening
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Colon Cancer Screening
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Biopsy
Patient’stissue sample or
blood sample Genomic profile
Proteomic profile
Pathology
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Microscopic Appearance of Cancer Cells
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Tumor Staging and GradingTumor Staging and Grading• Staging determines size of tumor and
existence of metastasis• Grading classifies tumor cells by type
of tissue• The TNM system is based on the
extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (early cancer that has not spread to neighboring tissue)
T1, T2, T3, T4 Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement (no cancer found in the lymph nodes)
N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)
Distant Metastasis (M)
MX Distant metastasis cannot be evaluated
M0 No distant metastasis (cancer has not spread to other parts of the body)
M1 Distant metastasis (cancer has spread to distant parts of the body)
NURSING DIAGNOSESNURSING DIAGNOSES• Acute or chronic pain• Impaired skin integrity• Impaired oral mucous membrane• Risk for injury• Risk for infection• Fatigue • Imbalanced nutrition: less than body
requirements
NURSING DIAGNOSESNURSING DIAGNOSES
• Risk for imbalanced fluid volume• Anxiety • Disturbed body image• Deficient knowledge• Ineffective coping• Social isolation
OUTCOME IDENTIFICATIONOUTCOME IDENTIFICATION1. Pain relief2. Integrity of skin and oral mucosa3. Absence of injury and infection4. Fatigue relief5. Maintenance of nutritional intake
and fluid and electrolyte balance6. Improved body image7. Absence of complications
OUTCOME IDENTIFICATION
8. Knowledge of prevention and cancer treatment
9. Effective coping through recovery and grieving process
10.Optimal social interaction
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IMPLEMENTATION/IMPLEMENTATION/MANAGEMENTMANAGEMENT
• Prevention and detection– Primary Prevention
• Reducing modifiable risk factors in the external and internal environment
– Secondary Prevention• Recognizing early signs and symptoms and
seeking prompt treatment• Prompt intervention to halt cancerous
process
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Cancer Prevention
Cancer viruses or bacteria
Carcinogenic radiation
Carcinogenic chemicals
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Avoid Tobacco
15x
10x
5x
Non-smokerCigarettes Smoked per Day
Lung Cancer Risk Increases with Cigarette Consumption
Lung Cancer
Risk
0 15 30
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Protect Yourself From Excessive Sunlight
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Limit Alcohol and Tobacco
40x
30x
20x
10x
Alcoholic Drinks Consumed per Day
Packs of Cigarettes Consumed per Day
Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus
Risk Increase
AND
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Diet: Limit Fats and Calories
0
Number of Cases (per 100,000
people)
Grams (per person per day)
Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries
40
30
20
10
30020010080
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Diet: Consume Fruits and Vegetables
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Avoid Cancer Viruses
Noninfected women
HPV Infection Increases Risk for Cervical Cancer
Cervical Cancer
Risk
Low
High
Women infected with HPV
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Avoid Carcinogens at Work
Some Carcinogens in the Workplace
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Industrial Pollution
1930
Incidence of Most Cancers
Year199019701950
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TREATMENT MODALITIESTREATMENT MODALITIES• Aimed towards:
– CURE - free of disease after treatment → normal life
– Control - Goal for chronic cancers– Palliative Care: Quality of life maintained
at highest level for the longest possible time
• Surgery – surgical removal of tumors; most commonly used treatment
• Preventive or prophylactic• Diagnostic surgery• Curative surgery• Reconstructive surgery• Palliative surgery
• Chemotherapy – use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction
• Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues – Teletherapy (external): radiation
delivered in uniform dose to tumor– Brachytherapy: delivers high dose to
tumor and less to other tissues; radiation source is placed in tumor or next to it
• Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses.
• Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way
• Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient
• Gene therapy – transfer of genetic materials into the client’s DNA
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NURSING MANAGEMENTNURSING MANAGEMENT1. Promote measures that relieve pain and
discomfort.• Pharmacologic and non-pharmacologic
interventions
2. Promote measures to maintain intact skin integrity
3. Promote measures that maintain oral mucosa4. Promote measures to prevent injury from
abnormal bleeding• Monitor platelet count; avoid aspiring products,etc
NURSING MANAGEMENT5. Promote measures that identify and
prevent infection• Monitor WBC count; encourage frequent
handwashing and overall cleanliness
6. Help decrease the client’s fatigue and increase his activity level
7. Promote measures that ensure adequate nutritional intake
• High protein, high calorie diet
8. Ensure adequate fluid and electrolyte balance
NURSING MANAGEMENT9. Promote measures to enhance body image.
• Take an honest gentle, caring approach; encourage client to express and verbalize feelings
10.Promote measures that address preventing complications of cancer therapy
11. Instruct client and family about the disease process and treatments; provide necessary information for self-care.
12.Help client and family cope effectively13.Promote measures to reduce social isolation.
Care of Clients Receiving Care of Clients Receiving ChemotherapyChemotherapy
• Classes of Chemotherapy Drugs:
• Alkylating agents:– Action: create defects in tumor DNA– Ex: Nitrogen Mustard, Cisplatin– Toxic Effects: reversible renal tubular
necrosis
Classes of Chemotherapy Drugs
• Antimetabolites:– Action: phase specific– Ex: Methotrexate; 5 fluorouracil– Toxic Effects: nausea, vomiting,
stomatitis, diarrhea, alopecia, leukopenia
Classes of Chemotherapy Drugs
• Antitumor Antibiotics:– Action: non- phase specific; interfere
with DNA– Ex: Actinomycin D, Bleomycin,
adriamycin (doxorubicin)– Toxic Effect: damage to cardiac muscle
Classes of Chemotherapy Drugs
• Miotic inhibitors:– Action: Prevent cell division during M
phase of cell division– Ex: Vincristine, Vinblastine– Toxic Effects: affects neurotransmission,
alopecia, bone marrow depression
Classes of Chemotherapy Drugs
• Hormones:– Action: stage specific G1– Ex: Corticosteroids
• Hormone Antagonist:– Action: block hormones on hormone- binding
tumors ie: breast, prostate, endometrium; cause tumor regression
– Ex: Tamoxifen (breast); Flutamide (prostate)– Toxic Effects: altered secondary sex
characteristics
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Effects of ChemotherapyEffects of Chemotherapy• Tissues: (fast growing) frequently
affected• Examples: mucous membranes, hair
cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)
Chemotherapy Chemotherapy AdministrationAdministration
• Routes of administration:– Oral– Body cavity (intraperitoneal or
intrapleural)– Intravenous
• Use of vascular access devices because of threat of extravasation (leakage into tissues) & long-term therapy
Chemotherapy Administration
• Types of vascular access devices:– PICC lines: (peripherally inserted central
catheters) – Tunneled catheters: (Hickman,
Groshong)– Surgically implanted ports: (accessed
with 90o angle needle- Huber needles)
Nursing care of clientsNursing care of clientsreceiving chemotherapyreceiving chemotherapy
• Assess and manage:– Toxic effects of drugs (report to
physician)– Side effects of drugs: manage nausea
and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions
Nursing care of clientsreceiving chemotherapy
• Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration
• Assess for dehydration, oncologic emergencies
• Teach regarding fatigue, immunosuppression precautions
• Provide emotional and spiritual support to clients and families
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REFERENCE• National Cancer Institute• Brunner and Suddarth’s Medical
Surgical Nursing
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