WR (Oncologic Nursing)

ONCOLOGIC NURSING
(Written Report)

Prepared by: Briones, Liset Grace M. Gutierrez, Emmanuel A. Palatino, Carol Joy Z.

Submitted to: Ms. Joanne Otilano, RN

ONCOLOGIC NURSING A. Overview of The Normal Cell 1. Structure and Function of the Cell Cell is the basic structure and function unit of a modern organism. In DNA, it stores information, its structure, and processes. It has all the machinery to build structures and performs function to keep itself alive. All the cells of the body are constantly bathed in a dilute saltwater solution which is derived from the blood. It varies in length from 2mm to 3ft. It also varies in shape like disk shaped (RBC), threadlike extensions (nerve cells), toothpick or pointed end (smooth muscle cells), cubelike (epithelial cells). According to the presence or absence of nucleus: Prokaryotes- pre nucleus or before nucleus , found in bacteria/archaebacteria, all the components including DNA, mingle freely in the cell s interior, a single compartment. Eukaryotes- true nucleus , found in plants, animals, fungi... a cell that contains a nucleus and a membrane bound organelles. The Major Parts of the Cell 1. Nucleus y y y y Headquarter or control center of the cell Contains the genetic materials (DNA)- a type of nucleic acid- blueprint that contains all the instructions needed for building the body It controls both biochemical reactions that occur in the cell and the production of the cell The nucleus decide what the cell needs and uses DNA to print out instructions for the rest of the cell to produce that need  Nuclear membrane  It seperates the chromosomes from the rest of the cells  Encloses a jelly-like fluid called NUCLEOPLASM in which the nucleoli and chromatin are suspended  The nucleus communicates through holes in the envelope called nuclear pores.  Nucleolus  pacemaker of the cell

 It is responsible in the synthesis of ribosomal RNA

 It is the site where the ribosomal RNA is synthesized and ribosomes subunits are assemble.  The nucleolus is like a tiny nucleus inside the actual nucleus. It contains RNA, a type of nucleic acid.  Chromatin granules  Composed primarily of CHON and RNA  Smaller than nucleoli and are irregular in size and shape. 2. Cytoplasm y y y Factory area of the cell Is the general storage and working area of the cell with the organelles and inclusions Kinds of cytoplasm: a. Ectoplasm- provides semisolid gel-liked support for the cell membrane. It is beneath the cell membrane frequently contains an interwoven mat of microfilaments composed mainly of actin fibrilae b. Endoplasm- the cytoplasm between the cortex and the nuclear membrane.  Inclusions- are lifeless accumulation of metabolites or cell products such as stored CHON, crystals pigment. They are dispensable and often temporary constituents of the cell.  Cytoplasmic organelles (little organ)- are compartmentalized structures that are perform a specialized function within a cell.  Endoplasmic reticulum  Ribosomes  Mitochondria  Lysosomes  Perixisomes  Golgi apparatus  Secretory vesicles  Centrioles  Filaments  Microtubules  Cytoskeleton

3. Cell membrane y y y y Plasma membrane of plasmalemma, is the limiting membrane of the cell It is made of phospholipids, which have CHO heads and lipid tails An important characteristic is selective permeability which determines the kinds and amount of substance passing into and out the cell. It serves as recognition sites acting as antigenic determinants which render the cell surface its immune-chemical properties. Proteins embedded into the membrane send and receive signals to communicate with other cells.

2. Cell Cycle The cell cycle is composed of four distinct phases during which the cell prepares for and undergoes mitosis. The G1 phase consists of cells that have recently completed division and are committed to continued proliferation. After a variable period, these cells begin synthesis DNA, marking the beginning of the S phase. After DNA synthesis is complete, the end of the S phase is followed by the premitotic rest interval called the G2 phase. Finally, chromosome condensation occurs and the cells divide during the mitotic M phase. Resting diploid cells that are not actively dividing are described as being in the G0 phase. The transition between cell-cycle phases is strictly regulated by specific signalling proteins; however, these cell-cycle checkpoints may become aberrant in some tumor types.

State Quiescent/ senescent Interphase

Phase Gap 0

Abbreviation G0

Description A resting phase where the cell has left the cycle and has stopped dividing

Gap 1

G1

Cells increase in size in Gap 1. The G1 checkpoint control mechanism ensures that everything is ready for DNA synthesis

Interphase

synthesis

S

DNA replication occurs during this phase

Interphase

Gap 2

G2

During the gap between DNA synthesis and mitosis, the cell will continue to grow. The G2 checkpoint control mechanism ensures that everything is ready to enter the M phase and divide.

Cell division

Mitosis

M

Cell growths stops at this stage and cellular energy are focused on the orderly division into two daughter cells. A checkpoint in the middle of mitosis ensures that the cell is ready to complete cell division.

B. Alteration in Cell Function AGING CELL A number of cellular structures or events appear to be involved in the process of aging. The major theories of aging concentrate on molecules within the cell, such as lipids, proteins, and nucleis acids. It is estimated that at least 35% of the factors affecting aging are genetic. 1. 2. 3. 4. Cellular clock. One theory on aging suggests that there is a cellular clock, which, after a certain passage of time or a certain number of cell divisions, results in death of a given cell line. Death genes. Another theory suggests that there are death genes , which turn on late in life, or sometimes prematurely, causing cells to deteriorate and die. DNA damage. Other theories suggest that through time, DNA is damaged, resulting in cell degeneration and death. Free radicals. DNA is also susceptible to direct damage, resulting in mutations, which may result in cellular dysfunction and ultimately, cell death. One of the major sources of DNA damage is apparently from free radicals, which are atoms or molecules with an unpaired electron. Mitochondrial damage. It may be that mitochondrial DNA is more sensitive to free-radical damage than is nuclear DNA. Mitochondrial DNA damage may result in loss of proteins critical to mitochondrial function. Because the mitochondria is a source of ATP, loss of mitochondrial function may result in the loss of energy critical to cell function and ultimately, to cell death. One proposal suggest that reduced caloric intake may reduce free radical damage to mitochondria.

5.

INJURED CELL Causes
o o o o

Hypoxia Physical Agents: (mechanical trauma, burns, frostbite, sudden changes in pressure (barotrauma), radiation, electric shock). Chemical Agents: glucose, salt, water, poisons (toxins), drugs, pollutants, insecticides, herbicides, carbon monoxide, asbestos, alcohol, narcotics, tobacco. Infectious Agents: prions, viruses, rickettsiae, bacteria, fungi, parasites.

o o o

Immunologic Reactions: anaphylaxis, autoimmune disease. Genetic Derangements: Congenital malformations, normal proteins (hemoglobinopathies), enzymes (storage diseases). Nutritional Imbalances: protein-calorie deficiencies, vitamin deficiencies; excess food intake (obesity, atherosclerosis).

Principles of Cell Injury Dependent upon the etiology, duration, severity of the inciting injury, cell type, stage of the cell cycle or cell adaptability o o o Cellular membranes, mitochondria, endoplasmic reticulum and the genetic apparatus are particularly vulnerable. Injury at one focus often has a cascade effect. Morphologic reactions occur only after critical biochemical damage. response of cell to any etiological factor; vulnerable to any pathophysiological

CELLULAR ALTERATION changes

a) Physiologic reaction b) Pathologic reaction c) 4 Cardinal Factors of Cellular Change: 1) Maintenance of cell membrane y cellular change = membrane permeability 2) Adenosine triphosphate (ATP) energy currency of the cell y Lesser ATP = lesser membrane permeability 3) Dioxyribonucleic acid (DNA) one of the last processes protected by the cell 4) Cellular protein (enzymes)

CELLULAR DEATH does not occur instantaneously because of adaptation 2 Types of Cellular Death: 1) Necrosis death of living cells or tissues 2) Apoptosis programmed cell death; important in development

4 Mechanisms of Necrosis: 1) Coagulative - Caused by ischemia; ischemia results in decreased ATP, increased cytosolic Ca++, and free radical formation, which each eventually cause membrane damage ( e.g Infarct: localized area of ischemic necrosis as in myocardial infarct ) a. Decreased ATP results in increased anaerobic glycolysis, accumulation of lactic acid, and therefore decreased intracellular pH.

2)

3)

4)

5)

b. Decreased ATP causes decreased action of Na+ / K+ pumps in the cell membranes, leading to increased Na+ and water within the cell (cell swelling). c. Other changes: Ribosomal detachment from endoplasmic reticulum; blebs on cell membranes, swelling of endoplasmic reticulum and mitochondria. d. Up to here, the changes are reversible if oxygenation is restored by reversing the ischemia. If the ischemia continues, necrosis results, causing the cytoplasm to become eosinophilic, the nuclei to lyse or fragment or become pyknotic (hyperchromatic and shrunken). In the early stages of necrosis, the cells remain for several days as ghosts of their former selves, allowing one to still identify them and the tissue (in contrast to the other types of necrosis). The cellular reaction is polys, followed by a granulation tissue response. Liquefactive Usually caused by focal bacterial infections, because they can attract polymorphonuclear leukocytes. The enzymes in the polys are released to fight the bacteria, but also dissolve the tissues nearby, causing an accumulation of pus, effectively liquefying the tissue. ( e.g. Abscess ) Caseous A distinct form of coagulative necrosis seen in mycobacterial infections (e.g., tuberculosis), or in tumor necrosis, in which the coagulated tissue no longer resembles the cells, but is in chunks of unrecognizable debris. Usually there is a giant cell and granulomatous reaction, sometimes with polys, making the appearance distinctive. Fat Necrosis - A term for necrosis in fat, caused either by release of pancreatic enzymes from pancreas or gut (enzymic fat necrosis) or by trauma to fat, either by a physical blow or by surgery (traumatic fat necrosis). The effect of the enzymes (lipases) is to release free fatty acids, which then can combine with calcium to produce detergents (soapy deposits in the tissues). Histologically, one sees shadowy outlines of fat cells (like coagulative necrosis), but with Ca++ deposits, foam cells, and a surrounding inflammatory reaction. Gangrene special type; combination of coagulative and liquefactive; occurs in limbs ( e.g. Diabetes Mellitus )

TYPES OF ADAPTATION: 1) Hypertrophy y Increase in cell size y Produces proteins ( growth factors ) y Physiologic 2) Hyperplasia y Increase in the number of cells y Stem cell y E.g. benign prostatic hyperplasia y Physiologic 3) Atrophy y Decrease in the size of cells y Neither / either physiologic or pathologic y Depends on etiology or condition of the patient 4) Metaplasia y Replacement of one adult cell type by a different adult cell type y Physiologic

y DNA adapts 5) Dysplasia y Changes in cell size, shape and organization y DNA is totally destroyed 6) Neoplasia y Abnormal cellular changes and growth of new tissues y Happens in cancer C. Etiologic Factors      VIRUSES  Oncogenic viruses may be one of the multiple agents acting to initiate carcinogenesis.  Prolonged or frequent viral infections may cause breakdown of the immune system or overwhelm of the immune system.  Viral infections that increase risk of certain forms of cancer are as follows: 1. Human papilloma virus Cervical cancer 2. Epstein-Barr virus Lymphoma 3. Hepatitis B and C Hepatocellular cancer 4. Helicobacter pylori Gastric cancer CHEMICAL CARCINOGENS  These factors act by causing cell mutation or alteration in cell enzymes and proteins causing altered cell replication.  Chemical carcinogens are as follows: 1. Industrial Compounds - Vinyl chloride ( used for plastic manufacture, asbestos factories, construction works ) - Polycyclic aromatic hydrocarbons ( such as from refuse burning, auto and truck emissions, oil refineries, air pollution ) - Fertilizers, weed killers - Dyes ( analine dyes used in beauty shops, hair bleach ) 2. Drugs - Tobacco, 90% of all cases of lung cancer are due to smoking - Alcohol - Cytotoxic drugs 3. Hormones Estrogen Viruses Chemical Carcinogens Physical Agents Hormones Genetics

- Diethylstilbestrol (DES) 4. Foods, preservatives - Nitrites ( bacon, smoked meat ) - Talc ( polished rice, salami, chewing gum ) - Food sweeteners - Nitrosamines ( rubber baby nipples ) - Aflatoxins ( mold in nuts and grains, milk, cheese, peanut butter ) 5. Polycyclic hydrocarbons - Charcoal broiling PHYSICAL AGENTS 1. Radiation from x-rays or radioactive isotopes; from sunlight / ultraviolet rays 2. Physical irritation / trauma from pipe smoking, multiple deliveries, jagged tooth, irritation of the tongue, overuse of any organ / body part HORMONES  Estrogen as replacement therapy has been found to increase incidence of vaginal, cervical and uterine cancers. GENETICS  When oncogene ( hidden or repressed genetic code for cancer that exists in all individuals ) is exposed to carcinogens, changes in cell structure occurs, malignant tumor develops.  Regardless of the cause, several cancers are associated with familial patterns ( e.g. retinoblastoma, pheochromocytoma, Wilm s tumor, lung cancer, breast cancer )

D. Predisposing Factors         AGE  Older individuals are more prone to cancer because they have been exposed to carcinogens longer. In addition, they have developed alterations in the immune system. SEX  The most common type of cancer in females is breast cancer. Whereas, the most common type of cancer in males is prostate cancer. Age Sex Urban residence Geographic distribution Occupation Heredity Stress Precancerous lesions

URBAN vs. RURAL RESIDENCE  Cancer is more common among urban dwellers than among rural residents. This is probably due to greater exposure to carcinogens, more stressful lifestyle, and greater consumption of preservative-cured foods among urban dwellers. GEOGRAPHIC DISTRIBUTION  The most common type of cancer in Japan is gastric cancer while the most common type of cancer in US is breast cancer. This may be due to influence of environmental factors such as national diet ( raw foods greatly consist Japanese diet ), ethnic customs, and types of pollutions. OCCUPATION  There is a greater risk of exposure to carcinogens among chemical factory workers, farmers, and radiology department personnel. HEREDITY  Positive family history of cancer increases the risk to develop the disease. In adults, approximately 34% of cancers have familial basis. Cancers that may have familial link include breast, ovarian, colorectal, prostate, melanoma, uterine, leukemia, sarcomas, and primary brain tumors. STRESS  Depression, grief, anger, aggression, despair or life stresses decrease immunocompetence because of affectation of hypothalamus and pituitary gland. Immunodeficiency may spur the growth and proliferation of cancer cells. PRECANCEROUS LESIONS  Pigmented moles, burn scars, senile keratosis, leukoplakia, benign polyps or adenoma of the colon or stomach, fibrocystic disease of the breast, may undergo transformation into cancerous lesions and tumors. OBESITY  Studies have linked obesity to breast and colorectal cancer. E. Pathophysiology of Cancer Over the past two decades, hundreds of cancer-associated genes have been discovered. Some, such as p53, are mutated in many different cancers; others, such as ABL1, are affected only in one or few. Each of the cancer-associated genes has a specific function, the dysregulation of which contributes to the origin or progression of malignancy. It is traditional to describe cancer-associated genes on the basis of their presumed function. It is beneficial, however, to consider cancer-related genes in the context ofseven fundamental changes in cell physiology that together determine malignant phenotype.(Another important change for tumor development is escape from immune attack. The seven key changes are the following:
y

Self-sufficiency in growth signals: Tumors have the capacity to proliferate without external stimuli, usually as a consequence of oncogene activation.

y

y y y

y

y

Insensitivity to growth-inhibitory signals: Tumors may not respond to molecules that are inhibitory to the proliferation of normal cells such as transforming growth factor (TGF- ) and direct inhibitors of cyclin-dependent kinases (CDKIs). Evasion of apoptosis: Tumors may be resistant to programmed cell death, as a consequence of inactivation of p53 or activation of anti-apoptotic genes. Limitless replicative potential: Tumor cells have unrestricted proliferative capacity, avoiding cellular senescence and mitotic catastrophe. Sustained angiogenesis: Tumor cells, like normal cells, are not able to grow without formation of a vascular supply to bring nutrients and oxygen and remove waste products. Hence, tumors must induce angiogenesis. Ability to invade and metastasize: Tumor metastases are the cause of the vast majority of cancer deaths and depend on processes that are intrinsic to the cell or are initiated by signals from the tissue environment. Defects in DNA repair: Tumors may fail to repair DNA damage caused by carcinogens or incurred during unregulated cellular proliferation, leading to genomic instability and mutations in protooncogenes and tumor suppressor genes.

Mutations in one or more genes that regulate these cellular traits are seen in every cancer. However, the precise genetic pathways that give rise to these attributes differ between individual cancers, even within the same organ. It is widely believed that the occurrence of mutations in cancer-related genes is conditioned by the robustness of the DNA-repair machinery, as well as protective mechanisms such as apoptosis and senescence that prevent the proliferation of cells with damaged DNA. Indeed, recent studies in a variety of human tumors, such as melanoma and prostate adenocarcinoma, have shown that oncogene-induced senescence, wherein mutation of a proto-oncogene drives cells into senescence rather than proliferation, is an important barrier to carcinogenesis.33 Some limits to neoplastic growth are even physical. If a tumor is to grow larger than 1 to 2 mm, mechanisms that allow the delivery of nutrients and the elimination of waste products must be provided (angiogenesis). Furthermore, epithelia are separated from the interstitial matrix by a basement membrane, composed of extracellular matrix molecules, that must be broken down by invasive carcinoma cells. These protective barriers, both intrinsic and extrinsic to the cell, must be breached, and feedback loops that normally prevent uncontrolled cell division must be disabled by mutations before a fully malignant tumor can emerge.

F. Classification of Neoplasm A tumor is said to be benign when its microscopic and gross characteristics are considered relatively innocent, implying that it will remain localized, it cannot spread to other sites, and it is generally amenable to local surgical removal; the patient generally survives. It should be noted, however, that benign tumors can produce more than localized lumps, and sometimes they are responsible for serious disease. Malignant tumors are collectively referred to as cancers, derived from the Latin word for crab, because they adhere to any part that they seize on in an obstinate manner, similar to a crab. Malignant, as applied to a neoplasm, implies that the lesion can invade and destroy adjacent structures and spread to distant sites (metastasize) to cause death. Not all cancers pursue so deadly a course. Some are discovered early and are treated successfully, but the designation malignant always raises a red flag. All tumors, benign and malignant, have two basic components: (1) clonal neoplastic cells that constitute their parenchyma and (2) reactive stroma made up of connective tissue, blood vessels, and variable numbers of macrophages and lymphocytes. Although the neoplastic cells largely determine a tumor's behavior and pathologic consequences, their growth and evolution is critically dependent on their

stroma. An adequate stromal blood supply is requisite for the tumor cells to live and divide, and the stromal connective tissue provides the structural framework essential for the growing cells. In addition, there is cross-talk between tumor cells and stromal cells that directly influences the growth of tumors. In some tumors, the stromal support is scant and so the neoplasm is soft and fleshy. In other cases the parenchymal cells stimulate the formation of an abundant collagenous stroma, referred to as desmoplasia. Some demoplastic tumors-for example, some cancers of the female breast-are stony hard or scirrhous. The nomenclature of tumors and their biologic behavior are based primarily on the parenchymal component. Benign Tumors In general, benign tumors are designated by attaching the suffix -oma to the cell of origin. Tumors of mesenchymal cells generally follow this rule. For example, a benign tumor arising in fibrous tisssue is called a fibroma, whereas a benign cartilaginous tumor is a chondroma. In contrast, the nomenclature of benign epithelial tumors is more complex. These are variously classified, some based on their cells of origin, others on microscopic pattern, and still others on their macroscopic architecture. Adenoma is applied to a benign epithelial neoplasm derived from glands, although they may or may not form glandular structures. On this basis, a benign epithelial neoplasm that arises from renal tubular cells growing in the form of numerous tightly clustered small glands would be termed an adenoma, as would a heterogeneous mass of adrenal cortical cells growing as a solid sheet. Benign epithelial neoplasms producing microscopically or macroscopically visible finger-like or warty projections from epithelial surfaces are referred to as papillomas. Those that form large cystic masses, as in the ovary, are referred to as cystadenomas. Some tumors produce papillary patterns that protrude into cystic spaces and are called papillary cystadenomas. When a neoplasm, benign or malignant, produces a macroscopically visible projection above a mucosal surface and projects, for example, into the gastric or colonic lumen, it is termed a polyp. Malignant Tumors The nomenclature of malignant tumors essentially follows the same schema used for benign neoplasms, with certain additions. Malignant tumors arising in mesenchymal tissue are usually called sarcomas (Greek sar = fleshy), because they have little connective tissue stroma and so are fleshy (e.g., fibrosarcoma, chondrosarcoma, leiomyosarcoma, and rhabdomyosarcoma). Malignant neoplasms of epithelial cell origin, derived from any of the three germ layers, are called carcinomas. Thus, cancer arising in the epidermis of ectodermal origin is a carcinoma, as is a cancer arising in the mesodermally derived cells of the renal tubules and the endodermally derived cells of the lining of the gastrointestinal tract. Carcinomas may be further qualified. Squamous cell carcinoma would denote a cancer in which the tumor cells resemble stratified squamous epithelium, and adenocarcinoma denotes a lesion in which the neoplastic epithelial cells grow in glandular patterns. Sometimes the tissue or organ of origin can be identified, as in the designation of renal cell adenocarcinoma or bronchogenic squamous cell carcinoma. Not infrequently, however, a cancer is composed of undifferentiated cells of unknown tissue origin, and must be designated merely as an undifferentiated malignant tumor. In many benign and malignant neoplasms, the parenchymal cells bear a close resemblance to each other, as though all were derived from a single cell. Indeed, neoplasms are of monoclonal origin, as is documented later. Infrequently, divergent differentiation of a single neoplastic clone along two lineages creates what are called mixed tumors.The best example of this is the mixed tumor of salivary gland origin. These tumors contain epithelial components scattered within a myxoid stroma that sometimes

contains islands of cartilage or bone. All these elements, it is believed, arise from a single clone capable of giving rise to epithelial and myoepithelial cells; thus, the preferred designation of these neoplasms is pleomorphic adenoma. The great majority of neoplasms, even mixed tumors, are composed of cells representative of a single germ layer. The multifaceted mixed tumors should not be confused with a teratoma, which contains recognizable mature or immature cells or tissues representative of more than one germ cell layer and sometimes all three. Teratomas originate from totipotential cells such as those normally present in the ovary and testis and sometimes abnormally present in sequestered midline embryonic rests. Such cells have the capacity to differentiate into any of the cell types found in the adult body and so, not surprisingly, may give rise to neoplasms that mimic, in a helter-skelter fashion, bits of bone, epithelium, muscle, fat, nerve, and other tissues. When all the component parts are well differentiated, it is a benign (mature) teratoma; when less well differentiated, it is an immature, potentially or overtly, malignant teratoma. A particularly common pattern is seen in the ovarian cystic teratoma (dermoid cyst), which differentiates principally along ectodermal lines to create a cystic tumor lined by skin replete with hair, sebaceous glands, and tooth structures. For generations, benign-sounding designations such as lymphoma, melanoma, mesothelioma, and seminoma have been used for certain malignant neoplasms. The converse is also true; ominous terms may be applied to trivial lesions. Hamartomas present as disorganized but benign-appearing masses composed of cells indigenous to the particular site. They were once thought to be a developmental malformation, unworthy of the -oma designation. For example, pulmonary chondroid harmatoma contains islands of disorganized, but histologically normal cartilage, bronchi, and vessels. However, many hamartomas, including pulmonary chondroid hamartoma, have clonal, recurrent translocations involving genes encoding certain chromatin proteins. Thus, through molecular biology they have finally earned their -oma designation. Another misnomer is the term choristoma. This congenital anomaly is better described as a heterotopic rest of cells. For example, a small nodule of well-developed and normally organized pancreatic substance may be found in the submucosa of the stomach, duodenum, or small intestine. This heterotopic rest may be replete with islets of Langerhans and exocrine glands. The term choristoma, connoting a neoplasm, imparts to the heterotopic rest a gravity far beyond its usual trivial significance. Although regrettably the terminology of neoplasms is not simple, it is important because it is the language by which the nature and significance of tumors are categorized.

G. Metastasis Metastases are tumor implants discontinuous with the primary tumor. Metastasis unequivocally marks a tumor as malignant because benign neoplasms do not metastasize. The invasiveness of cancers permits them to penetrate into blood vessels, lymphatics, and body cavities, providing the opportunity for spread. With few exceptions, all malignant tumors can metastasize. The major exceptions are most malignant neoplasms of the glial cells in the central nervous system, called gliomas, and basal cell carcinomas of the skin. Both are locally invasive forms of cancer, but they rarely metastasize. It is evident then that the properties of invasion and metastasis are separable. In general, the more aggressive, the more rapidly growing, and the larger the primary neoplasm, the greater the likelihood that it will metastasize or already has metastasized. There are innumerable exceptions, however. Small, well-differentiated, slowly growing lesions sometimes metastasize widely; conversely, some rapidly growing, large lesions remain localized for years. Many factors relating to both invader and host are involved.

Approximately 30% of newly diagnosed individuals with solid tumors (excluding skin cancers other than melanomas) present with metastases. Metastatic spread strongly reduces the possibility of cure; hence, short of prevention of cancer, no achievement would be of greater benefit to patients than methods to block metastases. Pathways of Spread Dissemination of cancers may occur through one of three pathways: (1) direct seeding of body cavities or surfaces, (2) lymphatic spread, and (3) hematogenous spread. Although direct transplantation of tumor cells, as for example on surgical instruments, may theoretically occur, it is rare and we do not discuss this artificial mode of dissemination further. Each of the three major pathways is described separately. 1. Seeding of Body Cavities and Surfaces Seeding of body cavities and surfaces may occur whenever a malignant neoplasm penetrates into a natural "open field." Most often involved is the peritoneal cavity (Fig. 7-16), but any other cavity-pleural, pericardial, subarachnoid, and joint space-may be affected. Such seeding is particularly characteristic of carcinomas arising in the ovaries, when, not infrequently, all peritoneal surfaces become coated with a heavy layer of cancerous glaze. Remarkably, the tumor cells may remain confined to the surface of the coated abdominal viscera without penetrating into the substance. Sometimes mucus-secreting appendiceal carcinomas fill the peritoneal cavity with a gelatinous neoplastic mass referred to as pseudomyxoma peritonei. 2. Lymphatic Spread Transport through lymphatics is the most common pathway for the initial dissemination of carcinomas and sarcomas may also use this route. Tumors do not contain functional lymphatics, but lymphatic vessels located at the tumor margins are apparently sufficient for the lymphatic spread of tumor cells.11 The emphasis on lymphatic spread for carcinomas and hematogenous spread for sarcomas is misleading, because ultimately there are numerous interconnections between the vascular and the lymphatic systems. The pattern of lymph node involvement follows the natural routes of lymphatic drainage. Because carcinomas of the breast usually arise in the upper outer quadrants, they generally disseminate first to the axillary lymph nodes. Cancers of the inner quadrants drain to the nodes along the internal mammary arteries. Thereafter the infraclavicular and supraclavicular nodes may become involved. Carcinomas of the lung arising in the major respiratory passages metastasize first to the perihilar tracheobronchial and mediastinal nodes. Local lymph nodes, however, may be bypassed-socalled "skip metastasis"-because of venous-lymphatic anastomoses or because inflammation or radiation has obliterated lymphatic channels. In breast cancer, determining the involvement of axillary lymph nodes is very important for assessing the future course of the disease and for selecting suitable therapeutic strategies. To avoid the considerable surgical morbidity associated with a full axillary lymph node dissection, biopsy of sentinel nodes is often used to assess the presence or absence of metastatic lesions in the lymph nodes. A sentinel lymph node is defined as "the first node in a regional lymphatic basin that receives lymph flow from the primary tumor." Sentinel node mapping can be done by injection of radiolabeled tracers and blue dyes, and the use of frozen section upon the sentinel lymph node at the time of surgery can guide the surgeon to the appropriate therapy. Sentinel node biopsy has also been used for detecting the

spread of melanomas, colon cancers, and other tumors. In many cases the regional nodes serve as effective barriers to further dissemination of the tumor, at least for a while. Conceivably the cells, after arrest within the node, may be destroyed by a tumorspecific immune response. Drainage of tumor cell debris or tumor antigens, or both, also induces reactive changes within nodes. Thus, enlargement of nodes may be caused by (1) the spread and growth of cancer cells or (2) reactive hyperplasia. Therefore, nodal enlargement in proximity to a cancer, while it must arouse suspicion, does not necessarily mean dissemination of the primary lesion. 3. Hematogenous Spread Hematogenous spread is typical of sarcomas but is also seen with carcinomas. Arteries, with their thicker walls, are less readily penetrated than are veins. Arterial spread may occur, however, when tumor cells pass through the pulmonary capillary beds or pulmonary arteriovenous shunts or when pulmonary metastases themselves give rise to additional tumor emboli. In such vascular spread, several factors influence the patterns of distribution of the metastases. With venous invasion the blood-borne cells follow the venous flow draining the site of the neoplasm, and the tumor cells often come to rest in the first capillary bed they encounter. Understandably the liver and lungs are most frequently involved in such hematogenous dissemination because all portal area drainage flows to the liver and all caval blood flows to the lungs. Cancers arising in close proximity to the vertebral column often embolize through the paravertebral plexus, and this pathway is involved in the frequent vertebral metastases of carcinomas of the thyroid and prostate. Certain cancers have a propensity for invasion of veins. Renal cell carcinoma often invades the branches of the renal vein and then the renal vein itself to grow in a snakelike fashion up the inferior vena cava, sometimes reaching the right side of the heart. Hepatocellular carcinomas often penetrate portal and hepatic radicles to grow within them into the main venous channels. Remarkably, such intravenous growth may not be accompanied by widespread dissemination. Histologic evidence of penetration of small vessels at the site of the primary neoplasm is obviously an ominous feature.

H. Effects of Neoplasm Ultimately the importance of neoplasms lies in their effects on patients. Although malignant tumors are of course more threatening than benign tumors, any tumor, even a benign one, may cause morbidity and mortality. Indeed, both malignant and benign tumors may cause problems because of (1) location and impingement on adjacent structures, (2) functional activity such as hormone synthesis or the development of paraneoplastic syndromes, (3) bleeding and infections when the tumor ulcerates through adjacent surfaces, (4) symptoms that result from rupture or infarction, and (5) cachexia or wasting. Local and Hormonal Effects Location is crucial in both benign and malignant tumors. A small (1-cm) pituitary adenoma, though benign and possibly nonfunctional, can compress and destroy the surrounding normal gland and thus lead to serious hypopituatarism. Cancers arising within or metastatic to an endocrine gland may cause an endocrine insufficiency by destroying the gland. Neoplasms in the gut, both benign and malignant, may cause obstruction as they enlarge. Infrequently, peristaltic movement telescopes the neoplasm and its affected segment into the downstream segment, producing an obstructing intussusception.

Hormone production is seen with benign and malignant neoplasms arising in endocrine glands. Such functional activity is more typical of benign than of malignant tumors, which may be sufficiently undifferentiated to have lost such capability. A benign beta-cell adenoma of the pancreatic islets less than 1 cm in diameter may produce sufficient insulin to cause fatal hypoglycemia. In addition, nonendocrine tumors may elaborate hormones or hormone-like products and give rise to paraneoplastic syndromes (discussed later). The erosive and destructive growth of cancers or the expansile pressure of a benign tumor on any natural surface, such as the skin or mucosa of the gut, may cause ulcerations, secondary infections, and bleeding. Melena (blood in the stool) and hematuria, for example, are characteristic of neoplasms of the gut and urinary tract. Neoplasms, benign as well as malignant, may cause problems in varied ways, but all are far less common than the cachexia of malignancy. Cancer Cachexia Individuals with cancer commonly suffer progressive loss of body fat and lean body mass accompanied by profound weakness, anorexia, and anemia, referred to ascachexia. Unlike starvation, the weight loss seen in cachexia results equally from loss of fat and lean muscle. There is some correlation between the tumor burden and the severity of the cachexia. However, cachexia is not caused by the nutritional demands of the tumor. In persons with cancer, the basal metabolic rate is increased, despite reduced food intake. This is in contrast to the lower metabolic rate that occurs as an adaptational response in starvation. Although patients with cancer are often anorexic, cachexia probably results from the action of soluble factors such as cytokines produced by the tumor and the host rather than reduced food intake. The basis of these metabolic abnormalities is not fully understood. It is suspected that TNF produced by macrophages in response to tumor cells or by the tumor cells themselves mediates cachexia. TNF at high concentrations may mobilize fats from tissue stores and suppress appetite; both activities would contribute to cachexia. Other cytokines, such as IL-1, interferon- , and leukemia inhibitory factor, synergize with TNF. Additionally, other soluble factors produced by tumors, such as proteolysis-inducing factor and a lipid-mobilizing factor, increase the catabolism of muscle and adipose tissue.185 These factors reduce protein synthesis by decreasing m-RNA translation and by stimulating protein catabolism through the activation of the ATP-dependent ubiquitin-proteasome pathway. It is now thought that there is a balance between factors that regulate muscle hypertrophy, such as IGF, and factors that regulate muscle catabolism. In cachexia these homeostatic mechanisms are disrupted, tilting the scales toward cachectic factors. There is currently no satisfactory treatment for cancer cachexia other than removal of the underlying cause, the tumor. However, cachexia clearly hampers effective chemotherapy, by reducing the dosages that can be given. Furthermore, it has been estimated that a third of deaths of cancer are attributable to cachexia, rather than directly due to the tumor burden itself. Identification of the molecular mechanisms involved in cancer cachexia may allow treatment of cachexia itself. Paraneoplastic Syndromes Symptom complexes in cancer-bearing individuals that cannot readily be explained, either by the local or distant spread of the tumor or by the elaboration of hormones indigenous to the tissue from which the tumor arose, are known as paraneoplastic syndromes.186 These occur in about 10% of persons with malignant disease. Despite their relative infrequency, paraneoplastic syndromes are important to recognize, for several reasons:
y y

They may represent the earliest manifestation of an occult neoplasm. In affected patients they may represent significant clinical problems and may even be lethal.

y

They may mimic metastatic disease and therefore confound treatment.

I. Nine (9) Danger Signals of Cancer C-A-U-U-U-T-I-O-N !!!

C hange in Bowel or Bladder Habits  Alternating constipation and diarrhea is the most characteristic manifestation of colon cancer. Change in bladder habits may signify bladder or prostate cancer. A Sore that does Not Heal  A sore that does not heal characterize cancer because the tumor causes impaired circulation and oxygenation in the area. This leads to tissue necrosis, ulceration, bleeding and infection. U nusual Bleeding or Discharge  Unusual bleeding or discharge from the body part affected by cancer is also due to impaired circulation and oxygenation in the area. This leads to necrosis, ulceration, bleeding and infection. Infection causes unusual discharge. U nexplained Sudden Weight Loss  This is due to excessively rapid metabolism caused by the rapid multiplication of cancer cells. The normal cells are deprived of nutrients because of the cancer cells. U nexplained Anemia  Unexplained anemia is due to the following factors: a) the cancer cells take up iron faster than the normal cells b) bleeding contributes to anemia c) cancer cells tend to destroy normal RBCs T hickening or Lump in the Breast or elsewhere  This may signify abnormal cell growth. I ndigestion or Difficulty in Swallowing  Indigestion is the usual initial manifestation of gastric cancer. Difficulty in swallowing is a characteristic of cancer of the larynx and cancer of the esophagus. O- bvious Change in Wart or Mole  Sudden growth in size of wart or mole, uneven coloring, or change in the texture may signify transformation into a cancerous lesion. N agging Cough or Hoarseness of Voice  This signifies cancer of the larynx or cancer of the lungs.

J. Assessing patient with Cancer 1. History and Physical Assessment HISTORY 1. Breast Cancer  Early menarche  Late menopause  Nulliparous or older than 30 years at birth of a first child 2. Lung Cancer  Tobacco abuse  Asbestos  Radiation exposure  Air pollution 3. Colorectal Cancer  Greater incidence in men  Familial polyposis  Ulcerative colitis  High fat and Low fiber diet 4. Prostate Cancer  Common among males who are 50 years old and older  African Americans have the highest incidence of prostate cancer in the world.  Positive family history  Exposure to cadmium 5. Cervical Cancer  Sexual behavior - first sexual intercourse at an early age - multiple sexual partners - sexual partner who has had multiple sexual partner  Human papilloma virus and AIDS  Low socioeconomic status  Cigarette smoking 6. Head and Neck Cancer  More common among males  Alcohol and tobacco use  Poor oral hygiene  Long term sun exposure  Occupational exposures asbestos, tar, nickel, textile, wood or leather work, and machine tool experience 7. Skin Cancer  Individuals with fair complexion  Positive family history  Moles ( nevi )  Exposure to coal tar, creosote, arsenic, radium  Sun exposure between 11 AM to 3 PM

PHYSICAL ASSESSMENT Symptoms of cancer metastasis depend on the location of the tumor. Roughly, cancer symptoms can be divided into three groups: y Local symptoms: unusual lumps or swelling (tumor), hemorrhage (bleeding), pain and/or ulceration. Compression of surrounding tissues may cause symptoms such as jaundice (yellowing the eyes and skin). Symptoms of metastasis (spreading): enlarged lymph nodes, cough and hemoptysis, hepatomegaly (enlarged liver), bone pain, fracture of affected bones and neurological symptoms. Although advanced cancer may cause pain, it is often not the first symptom. Systemic symptoms: weight loss, poor appetite, fatigue and cachexia (wasting), excessivesweating (night sweats), anemia and specific paraneoplastic phenomena, (i.e. specific conditions that are due to an active cancer, such as thrombosis or hormonal changes).

y

y

Every symptom in the above list can be caused by a variety of conditions. Cancer may be a common or uncommon cause of each item. Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. Some cancers can be felt or seen through the skin - a lump on the breast or testicle can be an indicator of cancer in those locations. Skin cancer (melanoma) is often noted by a change in a wart or mole on the skin. Some oral cancers present white patches inside the mouth or white spots on the tongue. Other cancers have symptoms that are less physically apparent. Some brain tumors tend to present symptoms early in the disease as they affect important cognitive functions. Pancreas cancers are usually too small to cause symptoms until they cause pain by pushing against nearby nerves or interfere with liver function to cause jaundice. Symptoms also can be created as a tumor grows and pushes against organs and blood vessels. For example, colon cancers lead to symptoms such as constipation, diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in bladder function such as more frequent or infrequent urination. As cancer cells use the body's energy and interfere with normal hormone function, it is possible to present symptoms such as fever, fatigue, excessive sweating, anemia, and unexplained weight loss. However, these symptoms are common in several other maladies as well. For example, coughing and hoarseness can point to lung or throat cancer as well as several other conditions. When cancer spreads, or metastasizes, additional symptoms can present themselves in the newly affected area. Swollen or enlarged lymph nodes are common and likely to be present early. If cancer spreads to the brain, patients may experience vertigo, headaches, or seizures. Spreading to the lungs may cause coughing and shortness of breath. In addition, the liver may become enlarged and cause jaundice and bones can become painful, brittle, and break easily. Symptoms of metastasis ultimately depend on the location to which the cancer has spread. 2. Breast self Examination and Testicular Self Exam

BREAST SELF-EXAMINATION Inspection Before a Mirror Look for any change in size or shape; lumps or thickenings; any rashes or other skin irritations; dimpled or puckered skin; any discharge or change in nipples ( e.g. position or asymmetry ). Inspect the breasts in all of the following positions:  Stand and face the mirror with your arms relaxed at your sides or hands resting on hips; then turn to the right and the left for a side view. Look for any flattening in the side view. Bend forward from the waist with arms raised over the head. Stand straight with the arms raised over the head and move the arms slowly up and down at the sides. Look for free movement of the breasts over the chest wall. Press your hands firmly together at chin level while elbows are raised to shoulder level.

  

Palpation: Lying Position       Place a pillow under your right shoulder and place the right hand behind your head. This position distributes breast tissue more evenly on the chest. Use the finger pads of the three middle fingers ( held together ) of your left hand to feel for lumps. Press the breast tissue against the chest wall firmly enough to know how your breast feels. A ridge of firm tissue in the lower curve of each breast is normal. Use small circular motions systematically all the way around the breast as many times as necessary until the entire breast is covered. Bring your arm down to your side and feel under your armpit, where breast tissue is also located. Repeat the exam on your left breast, using the finger pads of your right hand.

Palpation: Standing or Sitting  Repeat the examination of both breasts while upright with one arm behind your head. This position makes it easier to check the area where a large percentage of breast cancers are found, the upper outer part of the breast and toward the armpit. Optional: Do the upright BSE in the shower. Soapy hands glide more easily over wet skin. Report any changes to your health care provider promptly.



TESTICULAR SELF-EXAMINATION     Choose one day of each month ( e.g. the first or the last day of each month ) to examine yourself. Examine yourself when you are taking a warm shower or bath. Support the testicle underneath with one hand. Place the fingers of the other hand under the testicle and the thumb on top. This may be easier to do if the leg on that side is raised. Roll each testicle between the thumb and fingers of your hand, feeling for lumps, thickening, or a hardening inconsistency. The testes should feel smooth.

   

Palpate the epididymis, a cordlike structure on the top and back of the testicle. The epididymis feels soft and not as smooth as a testicle. Locate the spermatic cord, or vas deferens, which extends upward from the scrotum toward the base of the penis. It should feel firm and smooth. Using a mirror, inspect your testicles for swelling, any enlargement, or lumps in the skin of the testicle. Report any lumps or other changes to your health care provider promptly.

3. Cancer Specified Diagnostic Examination A cancer diagnosis is based on assessment for physiologic and functional changes and results of the diagnostic evaluation. Patients with suspected cancer undergo extensive testing to: 1. 2. 3. 4. Determine the presence of tumor and its extent Identify the possible spread of disease or invasion of other body tissues Evaluate the function of involved and uninvolved body systems and organs Obtain tissue and cells for analysis, including evaluation of tumor stage and grade.

The diagnostic evaluation is guided by information obtained through a complete history and physical examination. Patients undergoing extensive testing are usually farfel of the procedures and anxious about the possible test result. The nurse can help relieve the patient s fear and anxiety by explaining the tests to be performed, the sensations likely to be explaining the test to be performed, and the patient s role in the test procedures. The nurse encourages the patient and the family to voice their fears about the results, supports the patient and family throughout the test period, and reinforces and clarifies information and conveyed by the physician. The nurse also encourages the patient and the family to communicate and share their concerns and to discuss their questions and concerns with each other. Cancer Specified Diagnostic Examination Test Tumor Marker Identification Description Analysis of the substances found in blood or other body fluids that are made by the tumor or by the body in response to the tumor or by the body in response to the tumor. Use of magnetic fields and radiofrequency signals to create sectional images of various body structures. Use of narrow-beam x-ray to scan successive layers of tissue for a cross-sectional view. Use of x-rays that identify contrasts in body tissue densities; may involve the use of contrast agents. High-frequency sound waves echoing off body tissues are converted electronically into images; used to assess Diagnostic Exam Breast , colon, lung, ovarian, testicular, prostate cancer Neurologic, pelvic, abdominal, thoracic cancer Neurologic, pelvic, skeletal, abdominal, thoracic cancers Skeletal, lungs, gastrointestinal cancers Abdominal and pelvic cancers

Magnetic resonance imaging (MRI) Computed tomography (CT) Fluoroscopy

Ultrasonography (ultrasound)

Endoscopy

Nuclear medicine imaging Positron emission tomography (PET)

tissues deep within the body. Direct visualization of a body cavity or passageway by insertion of an endoscope into a body cavity or opening; allows tissue biopsy, fluid aspiration, and excision of small tumors; both diagnostic and therapeutic. Uses intravenous injection or ingestion of radioisotope substances followed by imaging of tissues that have concentrated the radioisotopes. Through the use of tracer; provides black and white or color-coded images of the biologic activity of a particular area, rather than its structure; used in detection of cancer or its response to treatment.

Bronchial, gastrointestinal cancers

PET fusion

Use of PET scanner and CT scanner and CT scanner in one machine to provide an image combining anatomic detail, spatial resolution, and functional metabolic abnormalities.

Biopsy

The surgical removal of a small piece of tissue to determine whether the area is cancerous. Most frequently used for easily accessible tumors of the skin, breast, upper and lower gastrointestinal tract and upper respiratory tract. The surgeon can remove the entire tumor and surrounding marginal tissues as well. This removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic disease cells may lead to a recurrence of tumor. Is performed if the tumor mass is too large to removed. In this case, a wedge of tissue from the tumor is removed for analysis.

Bone, liver, kidney, spleen, brain, thyroid glands Lung, colon, liver, pancreatic, head and neck cancers; Hodgkin and non-Hodgkin lymphoma and melanoma Lung, colon, liver, pancreatic, head and neck cancers; Hodgkin and non-Hodgkin lymphoma and melanoma Colorectal, breast, ovarian, head and neck cancer; lymphoma and melanoma

Excisional biopsy

Incisional biopsy Are performed to sample suspicious masses that are easily accessible, such as some growths in the breasts, thyroid, lung, liver and kidney. Needle biopsies are fast, relatively inexpensive, and easy to perform and usually require only local anesthesia. It is a special x-ray examination of the breast made with specific x-ray equipment that can often find tumors too small to be felt. A mammogram is the best radiographic method available today to detect breast cancer early. An examination of the entire length of the colon using a Breast

Needle biopsies

Mammogram

Colonoscopy

Colon

Colposcopy PSA (Prostate Specific Antigen)

Papanicolaou test (Pap smear, Pap test, cervical smear, or smear test)

lighted, flexible tube. An examination of the cervix and vagina using an instrument called a colposcope. A substance (tumor marker) in the blood derived from the prostate gland. Its level may rise in prostatic cancer and is useful as a marker to monitor the effects of treatment. It is occasionally elevated as a result of nonmalignant conditions, such as benign prostatic hypertrophy. Should be evaluated in conjunction with other diagnostic tests such as digital rectal exam, transrectal ultrasound, and/or prostatic acid Phosphatase levels. A screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix.

Cervix, vagina

Cervix

Tumor Staging and Grading Staging It determines the size of the tumor and the existence of metastasis. Several systems exist for classifying the anatomic extent of disease. The TNM system is frequently used. T refers to the extent of the primary tumor, N refers to lymph node involvement and M refers to the extent of metastasis. A variety of other staging systems are used to describe the extents of cancers that are not well described by the TNM system. It also provide convenient shorthand notation that condenses lengthy descriptions into manageable terms for comparisons of treatment and prognoses. Grading It refers to classification of the tumor cells. Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue origin. Samples of cells to be used to establish the grade of a tumor may be obtained through cytology, biopsy or surgical excision. The tumor is assigned a numeric value ranging I to IV. Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue of origin in the structure and function. Tumors that do not clearly resemble the tissue of origin in the structure and function are described as poorly differentiated and are assigned grade IV. These tumors tend to be more aggressive and less responsive to treatment than well differentiated tumors. K. Common Malignancies y Breast cancer

y y y y y y y y y y y y

Bladder cancer Colon and rectal cancer Endometrial cancer Kidney cancer Lung cancer Melanoma Leukemia Non-hodgkin lymphoma Pancreatic cancer Prostate cancer Thyroid cancer Stomach cancer

K. Therapeutic and Nursing Modalities of Cancer  Support the idea that cancer is a chronic illness that has acute exacerbations rather than one that is synonymous with death and sufferings.  Assess own level of knowledge relative to the pathophysiology of the disease process.  Make use of current research findings and practices in the care o f the patient with cancer and his or her family.  Identify patient at high risk for cancer.  Participate in primary and secondary prevention efforts.  Assess the nursing care needs of the patient with cancer.  Assess the learning needs, desires, and capabilities of the patient with cancer.  Identify the nursing problems of the patient and the family.  Assess the social support networks available to the patient.  Plan appropriate interventions with the patient and the family.  Assist the patient to identify strengths and limitations.  Assist the patient to design short-term and long-term goals for care.  Implement a nursing care plan that interfaces with the medical care regimen and that is consistent with the established goals.  Collaborative with members of a multidisciplinary team to foster continuity of care.  Evaluate goals and resultant outcomes of care with the patient, the family, and the members of the multidisciplinary team.  Reassess and redesign the direction of the care as determined by the evaluation. Surgery Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. Surgery may be the primary method of treatment, or it may be prophylactic, palliative and reconstructive. Diagnostic Surgery

Diagnostic surgery, such as biopsy, is usually performed to obtain tissue sample for analysis of cells suspected to be malignant. Biopsy is taken from the actual tumor, but in some situations, it is necessary to biopsy lymph nodes near the suspicious tumor. Surgery as Primary Treatment Two common surgical approaches used for treating primary tumors are local and wide excisions. Local excision is warranted when the mass is small. It includes removal of the mass and a small margin of the normal tissues that is easily accessible. Wild or radical excision include removal of the primary tumor, lymph node, adjacent involve structures and surrounding tissue that may be at high risk for tumor spread. This surgical method can result in disfigurement and altered functioning. However, wide excisions are considered if the tumor can be removed completely and chances of cure and controlare good. Prophylactic Surgery It involves removing nonvital tissues or organs that are likely to develop cancer. The factor s are considered when physicians and patient discuss possible prophylactic surgery ;family history and genetic predisposition, presence or absence of symptoms, potential risks and benefits, ability to detect cancer at an early stage, the patient s acceptance of the post operative outcome. Palliative Surgery When cure is not possible, the goals of treatment are to make the patient as comfortable as possible and promote a satisfying and productive life for as long as possible. Palliative surgery is performed in an attempt to relieve complications of cancer. Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment.\ Reconstructive Surgery Reconstructive surgery may follow curative and radical surgery and is carried out in an attempt to improve function obtain a more desirable cosmetic effect. It may be performed in one operation or in stages. Reconstructive surgery may be indicated for breast, head and neck, and skin cancers. The nurse must recognize the patient s needs and the impact that altered functioning and altered body image must have on quality of life. The individual s needs of the patient undergoing reconstructive surgery must be accurately assessed and addressed. Chemotherapy In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replication. Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are amenable to surgery and radiation. Chemotherapy may be combined with surgery to reduce tumor size preoperatively, to destroy any remaining tumor cell postoperatively, or to

treat some forms of leukemia. The goals of chemotherapy (cure, control and palliation), must be realistic because they will define medications to be used and the aggressiveness of the treatment plan. Classification of Chemotherapeutic Agents Chemotherapeutic agent may be classified by their relationship with to the cycle. Certain chemotherapeutic agents are termed cell cycle-specific agents. These agent destroy cells that are actively reproducing by means of the cell cycle, most affect cells in the S phase by interfering with the DNA and RNA synthesis. Other agents, such as vinca or plant alkaloids, are specific to the M phase, where they half mitotic spindle formation. Chemotherapeutic agent that act independently of the cell cycle phases are termed cell cycle-nonspecific agents. These agents usually have a prolonged effect on the cells, leading to cellular damage or death. Many treatment plan combined cell cycle-specific and cell cycle-nonspecific agents to increase the number of vulnerable tumor cells killed during treatment period. Nursing Management in Chemotherapy Nurses play an important role in assessing and managing of many of the problems experienced by the patient undergoing chemotherapy. Chemotherapeutic agents have systemic effects on normal cells as well as malignant ones, which means that these problems are often widespread, affecting body systems. Assessing fluid and electrolyte Anorexia, nausea, vomiting, altered taste, and diarrhea put patients at risk for nutritional and fluid and electrolyte disturbances. It is important for the nurse to assess the patients nutritional and fluid and electrolyte status frequently and to use creative ways to encourage an adequate fluid and dietary intake. Modifying risk for infection and bleeding Nursing assessment and care focus on identifying and modifying factors that would further increased the patient s risk. Aseptic technique and gentle handling are indicated to prevent infections and trauma. The patient and family members are instructed about the measures to prevent these problems at home. Administering chemotherapy The local effects of the chemotherapeutic agent are also of concern. The patient is closely observed during its administration because of the risk and consequences of extravasation. Local difficulties or problems with administration of chemotherapeutic agents are brought to the attention of the physician promptly so that corrective measures can be taken immediately to minimize local tissue damage. Protecting caregivers Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the agents by direct contact, inhalation, or ingestion. Urinalyses of personnel repeatedly exposed to the cytotoxic agents have demonstrated mutagenic activity. The Occupational Safety and Health Administration,

Oncology Nursing Society, hospitals and other health care agencies have developed specific precautions for health care providers involved in preparation and administration of chemotherapy.