Cancer Development

I. Definitions A. Cancer - malignant neoplastic process that involves production of abnormal cells that do not obey the laws of normal tissue growth; NO !" actually # $%% diseases &. Neoplasm - tumor caused by abnormal cell growth - cells divide without a distinct purpose ; Cancer cells serve no useful purpose - Develop from normal cells Are all neoplasms cancer? A: No, some are benign ' types &enign (alignant Were cancer cells once normal? A: Yes, but changed to no longer look, grow or function normally II. !pidemiology ) NO !" Affects all races* ages* se+es and socioeconomic groups What are 2 reasons some cancers are more common today? A: Long life e pectancy of people in more affluent countries and increased e posure to substances that cause cancer ,econd only to heart disease as cause of death in -, $ of ' newly diagnosed cancer patients will survive When is someone considered to ha!e sur!i!ed cancer? A: Ali!e " years after diagnosis Why has progress been made in sur!i!al rates for some cancers? A: #arly diagnosis, increase in prompt treatment $within % months&, de!elopment of new diagnostic and treatment methods ,e+ and site Incidence of cancer greater in men Cancer of prostate* lung* and colon.rectum greatest in men; Cancer of breast* lung* and colon.rectum greatest in women ) ,ee /igure '0-1 p 2%' 3 able '0-$$ p 2%1 Why has lung cancer increased in women? A: 'ue to increase in smoking by women( )any years ago socially unacceptable for women to smoke Why would it be important to know which cancers are more pre!alent? A: *an direct limited resources at diagnosis and treatment of these cancers( can help in planning pre!ention and early detection strategies Age 0.2 of cancer deaths occur in persons over 44 years old 5ace Cancer incidence and mortality greater in blac6s than in whites; 7ispanic Americans have a decreased incidence and mortality 8eographic factors No place is free of cancer but differences in geographic distribution occur +i!e an e ample of a geographic difference in cancer distribution, A: *ancer of the breast has greater incidence in -. and Western #urope than /apan

III. 9athophysiology ,ee able '0-' p 0:: !+posure to carginogen DNA mutation damages suppressor genes prevents them from controlling e+pression of oncogenes oncogenes get turned on oncogenes overe+pressed e+cessive amounts of cyclins produced balance between cell growth enhancement and cell growth limitation is upset uncontrolled cell division failure of immune surveillance unrestrained replication of cancer cells malignant neoplasm Are oncogenes abnormal genes? Why? A: 0hey are normal cellular genes but ha!e limited function after early embryonic life( 0hey are usually 1turned off2, suppressed with little e pression or e pressed but tightly contolled

'oes cancer de!elop from 3ust one cancer cell? A: Yes, if growth conditions are right widespread metastatic disease can de!elop from one cancer cell( )ost tumors arise from cells that are capable of cell di!ision 4nce cancer cells ha!e grown to the point that a detectable tumor is formed $5cm in si6e& what must happen for the tumor to continue to grow and sur!i!e? A: 0umor must de!elop its own blood supply( 7n the early stages the tumor recei!es nutrition only through diffusion( 8owe!er when the tumor reaches 5 cm diffusion is not efficient and cells at the center of the tumor become hypo ic and start to die( 0o continue to sur!i!e and grow the tumor makes tumor angiogenesis factor $0A9& 0A9 triggers blood !essels in the area to grow new branches into the tumor Also get translocation and deletion of chromosomes Other characteristics of malignant cells" 9resence of Nuclei of various si;es (itotic figures which denote rapid and disorderly division of cells <ess contact inhibition cells pile up ,ee able '0-$ p 0:= Cell characteristics Mode of growth Capsule hape !ate of growth Metastasis !ecurrence General effects Destruction of tissue A"ilit# to cause death Nucleus Differentiated function Adherence Chromosomes BENIGN >ell differentiated 8rows by e+pansion /ibrous capsule -sually regular -sually slow None None -sually none None Not usually; -nless in a place where they could damage normal tissue e.g. brain ,mall (any ight !uploid MALIGNANT <oss of differentiation i.e.* anaplasia Infiltrates and destroys surrounding tissue i.e. invasion None Irregular with poorly defined border -sually rapid (etastasi;es (ay recur Often generali;ed effects !+tensive Causes death unless controlled <arge ,ame or none <oose Aneuploid

What does well differentiated and loss of differentiation mean? Why is this so important? A: Well differentiated means the cells resemble the parent tissue from which the tumor originated i,e, look like the tissue they come from( Loss of differentiation i,e, anaplasia means the cancer cells loose the specific appearance of their parent cells # tent of anaplasia indicates degree of malignancy i,e, poorly differentiated or undifferentiated means a high degree of malignancy and thus a poor prognosis What is the relationship between anaplasia and rate of growth? A: 0he more anaplastic a tumor the greater the rate of growth 'o cancer cells respond to signals for apoptosis? Why? A: No cancer cells do not respond to signals for apoptosis i,e, cell death( )ost cancer cells ha!e long telomeres and a lot of telomerase $an en6yme that maintains telemetric 'NA& *ancer cells ha!e an unlimited life span 8ow is tumor growth measured? A: :ate of growth is measured by tumor doubling time $median is ;< days& i,e, time it takes for tumor to double in si6e( Also measured by mitotic inde i,e, the = of acti!ely di!iding cells within a tumor > 5<= slow growing ? @" = fast growing Why do malignant tumors metastasi6e and benign tumors donAt? A: With benign tissues there is no migration of cells because they are tightly bound together and do not in!ade other body tissues( )igration of malignant cells occurs because they are not tightly bound together( 0here are many en6ymes on their cell surfaces that allow them to slip through blood !essels and tissues

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+i!e e amples of the generali6ed effects of malignant tumors, A: Anemia, weakness, weight loss, fatigue, cache ia Why are malignant cells loosely bound together? A: Because they do not make fibronectin, a protein that protrudes from normal cell membranes and allows cells to bind closely and tightly together 'o malignant cells e hibit contact inhibition? A: No, *ontact inhibition is the stopping of further rounds of cell di!ision when the di!iding cell is completely surrounded and touched by other cells What does euploid mean? Aneuploid? A: #uploid C normal number of chromosomes i,e, %; or 2D pair Aneuploid C abnormal number of chromosomes( *hromosomes are lost, gained, broken, or rearranged (etastasis ) ,ee able '0-0 p 2%$ ransplantation of tumor cells from $ organ or part to another that is separated by distance from the original tumor location (odes of dissemination <ocal spread - direct e+tension into neighboring tissue <ymphatic permeation and emboli;ation Once cells have invaded the lymph vessels they may detach and become emboli which lodge in the lymph node spread continues to the ne+t group of nodes and into other organs 7s the presence of cancer cells in the lymph nodes e!idence of spread? A: Yes 'oes the absence of cancer cells in the lymph nodes mean cancer has not spread? Why? A: No e!en if lymph node metastasis does not occur there may still be dissemination of malignant cells and malignant cells may pass through lymph nodes without lea!ing a trace ?ascular spread 8ow do cancer cells enter the blood !essels? A: #n6ymes on surface of cancer cells make large pores in blood !essels allowing tumor cells to enter the blood and circulate throughout the body( Because malignant cells are loosely held together, clumps of cells break off the primary tumor into blood !essels Occurs concurrently with lymphatic spread because of the presence of multiple lymphatic - venous interconnections throughout the body Invasion of body cavity by diffusion ,pread of clumps of cancer cells from surface of tumor by mechanical means 8ow can this occur? A: *lumps of cancer cells fall off surfaces of tumor into body ca!ity $particularly pre!alent in serous ca!ities $e,g, abdomen or pleural ca!ity&( *an also be implanted by surgeon into operati!e area

Common sites of metastasis - liver* lungs* bone marrow* brain* and adrenal gland 7f you e amine metastatic cells can you identify the primary tumor site? A: #arly in the metastatic process you can 7' the primary tumor site( #!en though tumor is in another organ, it is still cancer from the original altered tissue( #E: breast cancer that spreads to the lung is still breast cancer I?. Names of tumors ) ,ee able '0-2 p 2%$ A. &enign - name of parent tissue and @oma@ &. (alignant ' types Carcinoma - of epithelial origin ,arcoma - of connective tissue origin Named for scientist who first described them C. eratoma Contains embryonic elements of all 0 primary germ layers -sually benign

Often found in ovaries

?. Classification of umors Why is grading or staging of a tumor important? A: 8elps standardi6e cancer diagnosis, prognosis and treatment( )eans of e!aluating cancer for prognosis and appropriate therapy( Also allows health care professionals to e!aluate and compare management of cancer ' methods 8rading - according to histologic criteria ) ,ee able '0-4 p 2%' 8$ - >ell differentiated 8' - (oderately well differentiated 80* 82 - 9oorly to very poorly differentiated What happens to prognosis as the grade of a tumor increases? A: 0he higher the grade the more poorly differentiated and the worse the prognosis ,taging ) ,ee able '0-1 p 2%0 According to gross e+tent of tumor and e+tent of spread ,tages ,tage % - Cancer in situ What does cancer in situ mean? A: Fremalignant neoplasm that has not in!aded the basement membrane but shows cytologic characteristics of in!asi!e cancer ,tage I - umor limited to tissue of origin ,tage II - <imited to local spread ,tage III - !+tensive local and regional spread ,tage I? - (etastasis N( staging system umor % - No evidence of primary tumor $s - Carcinoma in situ $* '* 0* 2 - Ascending degrees of tumor si;e and involvement Nodes N% - No evidence of disease in lymph nodes N$a* N'a - Disease found in regional lymph nodes - metastasis not suspected N$b* N'b* N0b - Disease found in regional lymph nodes* metastasis suspected N+ - 5egional nodes cannot be assessed clinically (etastasis (% - no evidence of distinct metastasis ($* ('* (0 - Ascending degrees of metastatic involvement including distant nodes 7f the stage of a patientAs tumor is 02 N5 )< what does this mean? A: 0umor is mid si6e with one regional lymph node in!aded and no distant metastasis

?I. 9rocess of Carcinogenesis Initiation 9romotion 9rogression ?II. !tiology" Carcinogenesis A. Not fully understood &. Due to multiple factors +i!e an e ample of how multiple factors can lead to the de!elopment of cancer, A: #048 and tobacco are only mildly carcinogenic i,e, takes long e posure to large amounts of each alone to de!elop cancer but taken together enhance each otherAs carcinogenic acti!ity C. Carcinogenic factors What is the most important pre!entable source of cancer? A: 0obacco( D<= of cancers caused by tobacco

 7ost susceptibility What is the most important host susceptibility risk factor for carcinogenesis? A: N40#: 0he greatest risk is ad!ancing age because immune protection decreases and e ternal e posures to carcinogens accumulate 8enetic factors 7s genetic testing a definiti!e test for the de!elopment of cancer? A: +enetic tests do not diagnose the presence of cancer and do not confirm that cancer will definitely occur( A patientAs positi!e test results for a cancerGcausing gene mutation shows that he or she is at greatly increased risk for cancer de!elopment( 8owe!er the cancer still may ne!er occur What are the problems with genetic testing for cancer? A: # pensi!e and often are not co!ered by insurance( *ontrol of who will ha!e access to the information and whether to share the results with family members( 9ear of discrimination for insurance co!erage or in workplace Age Why does the incidence of cancer increase with age? A: As a person ages immune protection decreases and e ternal e posures to carcinogens accumulate 7ormonal factors +i!e an e ample of how hormonal factors might contribute to the de!elopment of cancer, A: 5 type of breast cancer is estrogen dependent which means it needs estrogen to grow and so treat with antiestrogen drug( Not primary carcinogens rather enhance carcinogenesis 9recancerous lesions +i!e an e ample of a precancerous lesion and how this type of cancer is pre!ented, A: *olon polyps which are remo!ed during colonoscopy Chronic irritation* trauma* inflammation Why can chronically irritated tissues become cancerous? A: *hronically irritated tissues undergo freHuent cell di!ision and thus are at an increased risk for spontaneous 'NA mutation Immunologic factors Who has an increased risk of de!eloping cancer due to decreased immunity? A: Young and elderly due to decreased immunity, immunosuppressed due to disease $e,g, 87IJA7'.& or drugs $antire3ection drugs taken by transplant patients& Drug therapy +i!e an e ample of how a drug can be the source of cancer, A: #strogens, immunosuppressi!es, and cytoto ic agents 'iethystilbesterol C increased !aginal cancer in female offspring of mothers who took it !nvironmental factors 5adiation What are the 2 sources of radiation that cause cancer? +i!e an e ample of each, A: 5& 7oni6ing radiation from natural elements like radon and uranium and EGrays 2& -ltra!iolet radiation C from the sun, tanning beds, and germicidal lights Why are the cancer producing effects of radon gas more of a problem today? 8ow can this be pre!ented? A: :adon is an inert gas that emanates from the ground and stone building material due to decay of uranium( )ore of a problem now because homes are so well insulated( *an pre!ent problems with radon by keeping indoor en!ironment well !entilated and using radon testing kits Who ha!e a greater risk of cancer due to ultra!iolet radiation? A: Ferson who work outdoors and who ha!e light comple ions Chemical pollutants +i!e an e ample of e posure to a chemical that increases the risk of de!eloping cancer, A: #E: asbestos lung cancer

Air pollution !lectromagnetic fields 7ealth practices obacco use What types of cancer are associated with tobacco use? A: .ee 0able 2DGK p %<% Nutrition 7dentify K dietary habits that can reduce cancer risk? A: N40# 7mportant: .ee *hart 2DG5 p %<%

Alcohol ,e+ual practices ?iruses 8ow do some !iruses cause cancer? +i!e an e ample of how a specific !irus can cause cancer, A: Iiruses infect body cells and break 'NA strands insert their own genetic material into human 'NA can mutate normal cellAs 'NA and can acti!ate an oncogenes or damage suppressor genes C .ee 0able 2DG@ p %<% 9sychosocial factors ?III. 9revention of Cancer 9rimary prevention ) Includes +i!e a specific e ample of primary pre!ention of cancer? .econdary pre!ention? A: N40#: 7mportant to distinguish primary pre!ention measures from secondary pre!ention measures Frimary pre!ention includes a!oidance of known or potential carcinogens $e,g, a!oiding tobacco&, modification of associated factors $e,g, decrease fat and increase fiber in diet to decrease risk of colon cancer, and remo!al of 1at risk1 tissues $e,g, remo!ing colon polyps& .econdary pre!ention C regular screening for early detection of cancer $e,g, mammograms for women o!er %< and F.A le!els yearly& Avoidance of 6nown or potential carcinogens (odification of associated factors 5emoval of at ris6 tissue Chemoprevention What does chemopre!ention mean? +i!e an e ample, A: -ses drugs, chemicals, natural nutrients, or other substances to disrupt one or more steps important to cancer de!elopment( 0hese agents may be able to re!erse e isting gene damage or halt progress on of the transformation process #E: .uppression of carcinogenic action with A.A ,econdary prevention ,creening programs AC, guidelines for cancer related chec6ups in asymptomatic patients ,ee handout Cancers A warning signals What should a nurse do if a patient e hibits one of these K warning signals? ) ,ee able '0-: p 2%4 A: 0ell the patient to report symptoms to health care pro!iders $. '. 0. 2. 4. 1. A. Change in bowel or bladder habits A sore that does not heal -nusual bleeding or discharge hic6ening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness