NCM 104

Medical Surgical Nursing 2

Anthony P. Toledo, M.D, R.N

OUR LADY OF FATIMA UNIVERSITY

CANCER

Definition of Cancer

o Cancer is the general name given to a large group of diseases characterized by:

a. uncontrolled growth and spread of abnormal cells.

b. proliferation ( i.e. rapid production by cell division)

c. metastasis ( i.e.., spread or transfer of cancer cells from one organ not directly

connected)

o It affects people of all ages, most cancer occur in people older than 65 years of age.

o It is higher in men than women and higher in industrialized sectors & nations.

o Is second only to cardiovascular disease as the leading cause of death in the United States.

Different Kinds of Cancer

o Carcinomas- the most common types of cancer, arise from the cells that cover external

and internal body surfaces. Lung, breast, and colon are the most frequent type of cancers.

o Sarcomas- are cancers arising from cells found in the supporting tissues of the body such

as bone, cartilage, fat, connective tissue, and muscle.

o Lymphomas- are cancers that arise in the lymph nodes and tissues of the body's immune

system.

o Leukemias- are cancers of the immature blood cells that grow in the bone marrow and

tend to accumulate in large numbers in the bloodstream.

Etiology of Cancer

o Healthy cells are transformed by unknown mechanisms or exposure to certain

etiologic agents, including:

a. viruses ( e.g. Epstein- Barr, herpes simplex type II, cytomegalovirus,

papillomavirus, hepa B)

b. chemical carcinogens ( e.g. chromium, cobalt , tar, soot, asphalt, nitrogen

mustard, certain plastics, aniline dyes, hydrocarbons in cigarettes smoke, air

pollutants from industry, crude paraffin oil, nickel, asbestos, arsenicals)

c. physical stressors ( e.g. excessive exposure to sunlight or radiation, chronic

irritation )

d. hormonal factors ( e.g. imbalance of endogenous or exogenous hormones, such as

estrogen or diethylstilbestrol)

e. genetic factors ( e.g. abnormal chromosomes patterns, such as in Burkitt’s

lymphoma, chronic myelogenous or acute leukemia and skin cancers; familial

predisposition, such as in breast, endometrial, colorectal, stomach, lung, colon,

and kidney cancers)

f. dietary factors (e.g. fats, alcohol, salt-cured or smoked meats, foods containing

nitrates and nitrites, and a high caloric dietary intake)

Pathophysiology of Malignant Process

o Cancer is a disease process that:

Begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA.

The abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals in the environment surrounding the cell.

The cell acquires invasive characteristics, and changes occur in surrounding tissues.

The cell infiltrates these tissues and gain access to lymph and blood vessels, which carry the cell to other areas of the body.

Metastasis (cancer spread to other parts of the body).

Proliferative Patterns

o Neoplasm (new cell growth) has several proliferative patterns:

a. Benign (i.e. usually harmless, does not infiltrate other tissues) and malignant (i.e.

always harmful; may spread or metastasize to tissues far from the original site)

cells display different characteristic of cellular growth; the degree of

differentiation (i.e. anaplasia) determines the potential for malignancy.

b. Hyperplasia involves an increase in the number of cells in a tissue; it may be a

normal or abnormal cellular response.

c. Metaplasia refers to the conversion of one type of cell in a tissue to another type

not normal for that tissue. It results from an outside stimulus affecting parent stem

cells and may be reversible. It could also progress to dysplasia.

d. Dysplasia refers to change in size, shape, or arrangement of normal cells into

bizarre cells; it may precede an irreversible neoplastic change.

e. Anaplasia involves a change in the DNA cell structure and in their orientation to

one another, characterized by a loss of differentiation and a return to a more

primitive form. The resulting poorly differentiation, irregularly shaped cells

usually are malignant.

Characteristics of Benign and Malignant Neoplasms

Characteristics Benign Malignant

Cell Characteristics

Well Differentiated cells that resemble normal cells of the tissue from which the tumor originated.

Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose.

Mode of Growth

Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated.

Grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues.

Rate of Growth Usually slow

Is variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth.

MetastasisDoes not spread by metastasis.

Gains access to the blood by lymphatic channels and metastasizes to other areas of the body.

General effects

Is usually a localized phenomenon that does not cause generalized effects unless its location interferes with vital functions.

Often causes generalized effects, such as anemia, weakness, and weight loss.

Tissue Destruction Does not usually cause tissue damage unless its location interferes with blood flow.

Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also

produce substances that cause cell damage.

Ability to cause death

Does not usually cause death unless its location interferes with vital functions.

Usually causes death unless growth can be controlled.

Invasion and Metastasis

o Invasion- refers to the growth of the primary tumor into the surrounding host tissues,

which occurs in several ways.

a. Mechanical pressure exerted by rapidly proliferating neoplasms

may force fingerlike projections of tumor cells into surrounding tissue and

interstitial spaces.

b. Malignant cells are less adherent and may break off from the

primary tumor and invade adjacent structures.

c. Malignant process is thought to possess or produce specific

destructive enzymes (proteinases), plasmonogen activators enzymes & lysosomal

hydrolyses. These enzymes are thought to destroy surrounding tissue, including

the structural tissues of the vascular basement membrane, facilitating invasion of

malignant cells.

d. The mechanical pressure of a rapidly growing tumor may

enhance this process.

o Metastasis- is the dissemination or spread of malignant cells from the primary tumor

to distant sites by direct spread of tumor cells to body cavities or through lymphatic

and blood circulation. Tumors growing in or penetrating body cavity and seed the

surfaces of other organs.

Mechanism of Metastasis

o Lymph and blood are key mechanisms by which cancer cells spread.

o Angiogenesis- is a mechanism by which the tumor cells are ensured a blood supply is

another important process.

Lymphatic Spread

o Lymphatic spread is the transport of tumor cells through the lymphatic

circulation; and the most common mechanism of metastasis.

o Malignant cells may also penetrate the lymphatic circulation by invasion.

Tumor emboli enter the lymph channels by way the interstitial fluid, which

communicate with lymphatic fluid.

Malignant Cells either lodge in the lymph nodes or pass between the lymphatic &

venous circulation.

Tumors arise in areas of the body with rapid and extensive lymphatic circulations

are high risks for metastasis through lymphatic channels.

Hematogenous Spread

o Hematogenous spread is the dissemination of malignant cells via the bloodstream.

o It is directly related to the vascularity of the tumor.

o Few malignant cells can survive the turbulence of arterial circulation, insufficient

oxygenation, or destruction by the body’s immune system.

o The survived malignant cells are able to attach to endothelium and attract fibrin,

platelets, and clotting factors to seal themselves from immune system.

o The endothelium retracts that allows the malignant cells to enter the basement

membrane & secrete lysosomal enzymes.

o These enzymes destroy surrounding body tissues and allow implantation.

Angiogenesis

o Angiogenesis is the growth of new capillaries from the host tissue by the release of

growth factors and enzymes such as vascular endothelial growth factor (VEGF).

o These proteins rapidly stimulate formation of new blood vessels, which help

malignant cells obtain the necessary nutrients and oxygen.

o Large tumor emboli that become trapped in the microcirculation of distant sites

may further metastasize to other sites.

Carcinogenesis (has three steps)

1. Initiation- initiators (carcinogens) escape normal enzymatic mechanisms and

alter the genetic structure of the cellular DNA.

2. Promotion- repeated exposure to promoting agents (cocarcinogens) causes the

expression of abnormal or mutant genetics information even after long latency

periods.

3. Progression- the cellular changes formed during initiation and promotion

exhibit increased malignant behavior. These cells have a propensity to invade

adjacent tissues and to metastasize. Agents that initiate or promote cellular

transformation are referred as carcinogens.

Role of the Immune System

o The term "immune system"—as recognized by scientists—refers to the

enormously complex interaction of many types of cells (T-cells, B-cells, N-K cells,

helper cells, suppressor cells, macrophages, etc.), cell products (many lymphokines,

cytokines and cytotoxins), other substances (chemicals, hormones), and physical agents

(X-rays, ultraviolet light).

o Some evidences indicate that the immune system can detect the development of

malignant cells and destroy them before cell growth becomes uncontrolled.

o At this time there is no single, valid measure of an individual's

"immunocompetence." What we do have is various tests related to the body's ability to

react to the foreign proteins found in viruses, bacteria, foods, and other sources.

o These tests include:

1. Protein electrophoresis, to measure the types and amounts of immunoglobulins

in the serum of the patient. Antibodies are immunoglobulins, but not all

immunoglobulins are antibodies.

2. Immunoelectrophoresis, to identify the amount and kind of immunoglobulins

but not specific antibodies.

3. Immunochemical electrophoresis, to identify specific antibodies in the serum.

4. Allergy tests, to determine the presence or absence of antibodies in the blood

stream.

5. Patch testing, using chemicals like CDNB), PPD, mumps skin test, etc., is used

together with allergy tests.

6. The determination of the proportion of T-4 and T-8 cells in the blood of the

patient (cellular immune system).

Immunoincompetent patients

a. Organ transplant recipients (under immunosuppressive therapy to prevent

rejection of transplanted organ).

b. AIDS Patients

c. Patients under alkylating chemotherapeutic agents.

d. Patients with Auto immune diseases (such as Rheumatoid Athritis).

e. Patients with declining organ functions (age related) .

Normal Immune Response

o Normally, the body has the ability to combat cancer cells in several ways:

a. TUMOR ASSOCIATED ANTIGENS, are capable of recognizing foreign antigens

and are capable of stimulating both the humoral and cellular immune responses.

b. T LYMPHOCYTES, along with macrophages (soldiers of the cellular immune

response), are responsible for recognizing tumor related antigens and stimulate other

components to get rid of malignant cells, including cytotoxic properties.

c. INTERFERON (IFN), substances produce by the body in response to viral infection,

possesses some anti tumor properties.

d. B LYMPHOCYTES, produces antibodies that also defend the body against

malignant cells

e. NATURAL KILLER CELLS (NK), directly destroy cancer cells and produces

lymphokines and enzymes that assist in cell destruction.

Immune System Failure

o Properly used, the term "immunosuppressed" refers to evidence based on the

above tests that a malfunction exists in a patient's immune system.

o To define the malfunction, one must identify the specific fault in the system.

o A conclusion that someone is immunosuppressed should be based on precise and

extensive testing.

o Chemotherapy and radiation therapy sometimes decrease immune function. But

unless there is complete destruction—which is rare—recovery will take place, and

rebound above the normal level of activity may occur.

Detection and Prevention of Cancer

o Primary Prevention

a. Cancer prevention focuses on reducing modifiable risk factors in the external

and internal environment that increases a person’s susceptibility to cancer

development.

b. General factors that influence cancer incidence and mortality include sex, age,

geographic location, socioeconomic status, ethnic or cultural background,

personal habits, occupation, and personal and family health histories.

o Secondary prevention (involves detection and case-finding efforts to achieve early

diagnosis).

a. Recognizing early signs and symptoms and seeking prompt treatment can

significantly reduce morbidity and mortality of several types of cancer.

b. After early detection, prompt intervention may halt the cancerous process in

some cases.

Steps to Reduce Cancer Risk

1. Increase consumption of fresh vegetable (especially those of the cabbage family)

because studies indicate that roughage and vitamin-rich foods help to prevent certain

kinds of cancer.

2. Increase fiber intake because high –fiber diets may reduce the risk for certain

cancers (e.g. breast, prostate and colon).

3. Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal and

lung cancers.

4. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli,

which are thought to protect against stomach and esophageal cancers.

5. Practice weight control because obesity is linked to cancers of the uterus,

gallbladder, breast and colon.

6. Reduce intake of dietary fat because a high-fat diet increases the risk for breast,

colon, and prostate cancers.

7. Practice moderation and consumption of salt-cured, smoked and nitrate-cured

foods; these have been linked to esophageal and gastric cancers.

8. Stop smoking cigarettes and cigars, which are carcinogens.

9. Reduce alcohol intake because drinking large amounts of alcohol increases the

risk of liver cancers.

10. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to

prevent skin damage from ultraviolet rays that increase the risk of skin cancer

Diagnosis of Cancer and Related Nursing Considerations

o Patient with suspected cancer undergo extensive testing to:

1. Determine the presence of tumor and its extent.

2. Identify possible spread (metastasis) of disease or invasion of other body tissues.

3. Evaluate the function of involved and uninvolved body systems and organs.

4. Obtain tissue and cells for analysis including evaluation of tumor stage and grade.

o Diagnostic Aids Used to Detect Cancer

TEST DESCRIPTION DIAGNOSTIC TEST

Tumor marker identification

Magnetic resonance imaging

(MRI)

Computed tomography

Analysis of substances found in

blood or other body fluids that are

made by the rumor or by the body in

response to the tumor

Use of magnetic fields and

radiofrequency signals to create

sectioned images of a various body

structures

Use of narrow beam x-ray to scan

Breast, colon, lung, ovarian,

testicular, prostate cancers

Neurologic, pelvic, abdominal,

thoracic cancers

Neurologic, pelvic, skeletal,

Fluoroscopy

Ultrasonography (ultrasound)

Endoscopy

Nuclear medicine imaging

Positron emission tomography

(PET 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 contrasts agents

High-frequency sound waves

echoing off body tissues are

converted electronically into images;

used to assess 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

Computed cross-sectional images of

increased concentration of

radioisotopes in malignant cells

provide information about biologic

activity of malignant cells; help

distinguish between benign and

abdominal, thoracic

Skeletal, lung, gastrointestinal

cancers

Abdominal and pelvic cancers

Bronchial, gastrointestinal

cancers

Bone, liver, kidney, spleen,

brain, thyroid cancers

Lung, colon, liver, pancreatic,

breast, esophagus cancers;

Hodgkin’s and non- Hodgkin’s

lymphoma and melanoma

Radioimmunoconjugates

malignant processes and responses

to treatment

Monoclonal antibodies are labeled

with a radioisotope and injected

intravenously into the patient; the

antibodies that aggregate at the

tumor site are visualized with

scanners

Colorectal, breast, ovarian,

head and neck cancers;

lymphoma and melanoma

o Nursing Interventions

1. The nurse can help relieve the patient’s fear and anxiety by explaining the tests

to be performed, the sensations likely to be experienced, and the patient’s role in the test

procedures.

2. The nurse encourages the patient and family to voice their fears about the test

results, supports the patient and family throughout the test period, and reinforces and

clarifies information conveyed by the physician.

3. The nurse encourages the patient and family to communicate and share their

concerns and to discuss their questions and concerns with each other.

Tumor Staging and Grafting

o Staging – determines the size of the tumor and the existence of metastasis. The TNM

system is frequently used.

“T” – primary tumor

“N”- lymph node involvement

“M”- metastasis

o Grading - refers to the classification of the tumor cells. It seeks to define the

type of tissue from which cell retain the functional and histologic

characteristics of the tissue of origin.

- The tumor is assigned a numeric value ranging from grade I to IV.

- GX Grade cannot be assessed

G1 Well differentiated (Low grade)

G2 Moderately differentiated (Intermediate grade)

G3 Poorly differentiated (High grade)

G4 Undifferentiated (High grade)