Cancer is a disease of mutated cells that proliferate abnormally, creating pathology as a result of the abnormal cells’ demands on the body or by their direct effect on the body organs implicated in their growth. Many factors affect the development of cancer, but the exact processes are not well understood in the current state of medicine:
Etiology
Age is the single most important epidemiologic factor in the development of cancer. Most cancer occurs in people older than 65 years of age.
- Cancer is more common in industrialized sectors, and in men.
- Race may also predispose some populations to some types of cancer.
Carcinogenesis may also be induced by viruses, bacteria, physical agents (such as radiation), chemical agents (carcinogens), genetic factors, dietary factors, and hormonal agents.
| Characteristic | Benign Neoplasm | Malignant Neoplasm |
|---|---|---|
| Cell Characteristics | Well-differentiated cells that resemble normal cells | Undifferentiated; does not mimic its original tissue |
| Mode of Growth | Tumor grows by expanding; does not infiltrate surrounding tissues. This encapsulates the tumor as one large mass. | Grows at its edges by sending out processes that infiltrate and destroy surrounding tissues |
| Rate of Growth | Usually slow | Variable; can be fast. |
| Metastasis | Does not spread by metastasis | Invasive; Metastasizes through access to lymph nodes |
| General Effects | Usually localized; does not produce generalized effects unless its location affects vital functions | Often causes generalized effects (anemia, weakness, weight loss) |
| Tissue Destruction | Does not usually cause tissue damage unless its location interferes with blood flow | Extensive tissue damage either through overuse of blood supply or secretion of substances that cause cell damage |
| Ability to cause death | Usually does not result in death, unless the growth is located near vital functions | Usually causes death unless growth is controlled |
Assessment
An assessment for the presence of cancer may be done through the determination of signs and symptoms, palpable non-tender masses, and (definitively), a biopsy. If present, tumors are graded according to their size, lymph involvement, and metastatic status.
Tumor Markers
Some types of tumors can be detected through tumor markers found in the blood, some examples of which include Prostate-Specific Antigen (PSA) and Prostatic Acid Phosphatase (PAP) can point towards the presence of prostatic cancer, one of the most common forms of cancer in men.
Warning Signs of Cancer (CAUTION)
- Changes in bowel or bladder habits
- A non-healing sore
- Unusual bleeding or discharge
- Thickening or lumps in the breast
- Indigestion or difficulty in swallowing
- Obvious changes in warts or moles
- Nagging cough or hoarseness
Cancer Prevention
- Primary Prevention: lifestyle changes as health education for the clients:
- Avoid alcohol
- Avoid smoking
- Avoid fatty foods
- Secondary Prevention: early detection through:
| Cancer | Examination | Frequency |
|---|---|---|
| Breast (After menarche) | Breast Self-Examination | Monthly (1 week after menstruation) |
| Testicle | Testicular Self-Examiantion | Monthly |
| Colorectal (50 y.o.+) | Fecal Occult Blood Test | |
| Digital Rectal Examination | Every 5 years | |
| Flexible Sigmoidoscopy | Every 5 years | |
| Colonoscopy with Barium Enema | Every 10 years | |
| Prostate | Digital Rectal Examination | |
| Prostate Specific Antigen Test |
Cancer of the Breast
Etiology
- Genetic Factor: BRCA1 or BRCA2 (Family History)
- Advanced Age
- Hormonal Exposure: Estrogen
- Menstrual History: Early Onset/Menarche, Late Menopause
- Obstetric History: childbirth in advanced maternal age (30+); nulliparity
Breast cancer may appear as a hard, non-tender, irregular mass that appears with orange-peel skin and skin dimpling. Depending on the tumor size and lymph node involvement, the following is the staging for breast cancer:
- Stage 1: a tumor size of less than 2 centimeters
- Stage 2: a tumor size of less than 5 centimeters
- Stage 3: a tumor size of more than 5 centimeters, with lymph node involvement (axillary)
- Stage 4: metastasis has occurred
Management
- Surgery: lumpectomy (lump; breast-conserving surgery), simply mastectomy (breast), modified radical mastectomy (breast, lymph nodes), radical mastectomy (breast, lymph nodes, pectoralis muscle)
- Preoperative Management: psychosocial support and arm exercises (rope turning?)
- Postoperative: place the patient on (a) semi-fowlers, (b) monitor drainage, and (c) apply affected arm precautions (avoid all sources of trauma to the affected side).
- Chemotherapy
- Radiation Therapy
Nursing Interventions
Client Education: breast self-examination
Cancer of the Lungs
Bronchogenic Cancer includes cancer of the lungs. This is commonly brought upon by smoking, environmental hazards (air pollution, asbestos), and a familial history, among others. Its signs and symptoms include:
- Coughing, often chronic; more than a month
- Chest Pain
- Weight Loss
- Anorexia
Diagnostic examination of the lungs for determination of lung cancer include:
- X-ray
- CT Scan
- MRI
- Bronchoscopy: the use of an endoscope to directly visualize the airways
Management
The primary intervention is through surgery: lobectomy (lobe), pneumonectomy (lung, unilateral or bilateral), wedge resection (piece of the lung), segmentectomy (segment of the lung). Positioning after surgery follows the “LUPA” mnemonic:
- Post-Lobectomy: place the client on the unaffected side to promote drainage.
- Post-Pneumonectomy: place the client on the affected side to promote lung expansion.
Cancer of the Prostate
This is among the most common in the aged population of men. It has a considerable familial link, also increases with age, and may be caused by heavy metal exposure. It manifests as:
- Gross, Painless Hematuria: urinating large amounts of blood without pain.
- Difficulty in initiating urination and urinary retention from obstruction caused by the growth
- Bone pain, usually as a sign of metastasis
Management
- Radical Prostatectomy, or orchidectomy (testosterone is used for cancer growth; this removes testosterone).
- Radiation Therapy
- Pharmacologic Therpay: GnRH Analogues (inhibits luteinizing hormone, which inhibits testosterone production)
Multiple Myeloma
A malignant disease of the plasma cell. These result in the production of osteoclast-activating substances that destroy the bone.
- Bone pain, along the back or from the ribs; the classic symptom of multiple myeloma. This pain is chronic, and abates upon awakening but worsens during the day.
- Osteoclast activating factors are substances secreted by plasma cells that stimulate osteoclasts. This stimulates the process of bone resorption and bone destruction, which can result in pathologic fractures (osteoporosis) and hypercalcemia.
- Hypercalcemia produces excessive thirst, dehydration, constipation, and altered sensorium. The deposition of calcium in the kidney can also result in renal failure and kidney stones.
Management
There is no cure for multiple myeloma. However, chemotherapy and radiation can control symptoms and improve quality of life.
Chemotherapy
The administration of cytotoxic medication to promote tumor cell death, even if at the cost of normal cell death. It is preferably administered through IV, but this poses the risk of extravasation; the leakage of the chemotherapeutic agents into tissue, producing a deep chemical burn. Other methods of administration include:
- Topical
- Intrathecal: passage of chemotherapeutic medication through cerebrospinal fluid (CSF); through a lumbar puncture into the ommaya reservoir.
- Intracavitary: the introduction of chemotherapeutic medication into the peritoneum or other cavities of the body
- Intravesical: direct introduction of chemotherapeutic medication into targeted organs.
| Chemotherapeutic Agent | Method of Action | Side Effects |
|---|---|---|
| Alkylating Agents: Busulfan, Cyclophosphamide (Cytoxan) | Interferes with DNA Replication | Cytoxan: cystitis |
| Antimetabolites: 5-Fluorouracil, Methotrexate | Interferes with metabolites | Methotrexate: megaloblastosis |
| Cytotoxic Antibiotics: Bleomycin, Doxorubicin | Inhibits DNA and RNA synthesis | Doxorubicin: cardiotoxic (cardiac monitoring; WOF angina) |
| Plant Alkaloids: Vincristine, Vinblastine | Inhibits cell division (M phase) | Neurotoxic, producing paresthesia |
Side Effects
- Alopecia: hair loss occurring during chemotherapy; hair will return after chemotherapy ceases. Take note that hair is only washed three times a week, and not more frequently.
- Bone Marrow Suppression (Pancytopenia): reduction in WBC (immunosuppression), RBC (anemia), and platelet count (thrombocytopenia).
- Nausea and Vomiting: antiemetics (Omdansetron) are used 30 minutes prior to the administration of chemotherapy.
- Diarrhea: low fiber dieting
- Mucositis, Stomatitis: soft-bristled, electric toothbrush; avoid mouthwash containing alcohol. Additionally, smoking and alcohol are restricted.
Radiation Therapy
The use of physical radiation waves to reduce tumor size and kill tumor cells, which relieves obstruction and decreases pain. There are two modes of delivery for radiation therapy: external radiation or teletherapy, and internal radiation or brachytherapy
External radiation or “teletherapy” is the delivery of radiation externally to targeted areas.
- Side Effects: this may result in diarrhea, tissue damage, fatigue, and radiation pneumonia.
- Benefits: no risk for radiation exposure to others.
- Client instructions mainly intervene with the client’s skin over the treatment site to maintain its integrity:
- Protect the skin from sun exposure
- Avoid rubbing the treatment site
- Wash marked skin with plain water only; do not use powders, lotions, or soap.
- Wear loose-fitting clothing over the treatment area.
Internal radiation or “brachytherapy” is the use of implants (sealed; administered through beads, seeds, or needles) or systemic radiation (unsealed; administered orally or through IV) to deliver radiation to the relevant body systems.
- Side effects are similar to those in teletherapy.
- An issue
- Client instructions are related to potential unintended exposure to radiation. In unsealed internal radiation, excreted body fluids may be radioactive. Urine should be flushed thrice in order to reduce risks of contamination.
Safety Precautions
Patients on brachytherapy require a private room to avoid unintended exposure. For staff taking care of the patient, those who are pregnant are restricted, due to potential teratogenic effects of radiation on the fetus. Additionally, the following are instated to protect from radiation exposure:
- Exposure to the radioactive agents or patient is limited to 30 minutes over an 8 hour shift.
- Maintain a distance of 6 feet or more as much as possible. Limit close proximity to necessary procedures only.
- When providing care, a lead-lined shield is used to protect against radioactivity.
Oncologic Emergencies
- Superior Vena Cava Syndrome: the obstruction of the SVC by a growing tumor, which restricts venous return from the upper extremities and head. This produces (a) periorbital edema, (b) jugular vein distention, and (c) edema of the neck, arms, and hands. This may also result in seizures.
Treatment
Radiation is used to reduce tumor size, and seizure precautions are put in place in order to promote safety in the case of a potential seizure.
- Tumor Lysis Syndrome: the result of tumor cell destruction from treatment, which releases cell contents such as calcium and uric acid.
Treatment
- Hydration is used to offset the increased circulating substances (hemodilution).
- In the case of uric acid, medication such as allopurinol or febuxostat or dialysis may be required.
- Spinal Cord Compression: another complication produced by physical compression from tumor growth. This can result in back pain, leg pain, and paresthesias of the lower extremity as spinal function or mobility becomes impaired.
Treatment
Similar to SVC syndrome, the tumor size is surgically reduced.
- Disseminated Intravascular Coagulation (DIC): a bleeding disorder resulting from clot factor depletion due to prior clot formation secondary to sepsis. The main issue faced is blood loss.
Treatment
The main issue of blood loss is managed with blood transfusion, particularly with FFP to restore the clotting factors.