H.

ONCOLOGY
 General information
• Definitions
• cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues
• cancer types
• lymphoma and myeloma: cancers that begin in the cells of the immune system
• carcinoma: cancer that begins in the skin or in tissues that line or cover internal organs
• leukemia: cancer that starts in blood-forming tissue, e.g., bone marrow, and causes large numbers of abnormal blood cells to
be produced and enter the blood
• sarcoma: cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue
• central nervous system cancers: cancers that begin in the tissues of the brain and spinal cord
• types of tumors
• benign: refers to a tumor or growth that is not cancerous
• malignant: the uncontrolled growth of abnormal cells in the body, i.e., cancerous cells, which are spread through metastasis
• metastatic cancer: cancer that has spread from the place where it first started (primary site or site of origin) to
another place in the body (the secondary site)
• almost any cancer can form metastatic tumors
• most common sites of cancer metastasis: lungs, bones, liver
• staging: describes and classifies the size and/or extent (reach) of the original (primary) tumor and whether or not cancer
cells have spread in the body
• grading: describes the degree of malignancy according to the type of tumor cell
• indicates the degree of cell undifferentiation
• "well-differentiated" - when the tumor's tissue are closest to those of normal cells and tissue
• cancers with more abnormal-looking cells tend to grow and spread faster
• breast and prostate cancers have their own grading systems
Cancer Staging - TNM (or Modified Duke System)
T = tumor - based on the size of the original (primary) tumor and whether or not it has grown into nearby tissues
N = lymph nodes - whether or not the cancer has spread to the nearby lymph nodes
M = metastasis - whether or not the cancer has spread to distant areas of the body

CANCER Grading
GX: grade cannot be assessed (undetermined grade)
G1: well differentiated (localized with tumor limited to the tissue of origin)
G2: moderately differentiated (limited spread)
G3: poorly differentiated (extensive local and regional spreading)
G4: undifferentiated (distant metastasis)
Etiology
• generally unknown but may be caused by interacting factors
• cellular changes result from an interaction between a person's genetic factors and 3 categories of external agents
• physical carcinogens, e.g., ultraviolet radiation
• chemical carcinogens, e.g., asbestos, components of tobacco smoke, arsenic
• biological carcinogens, e.g. infections from certain viruses, bacteria or parasites
• familial risk for certain cancers, e.g., lung, stomach, breast, colon, rectum, and uterine
• cancer is the second most common cause of death in the U.S
• leading causes of cancer death among men: lung, prostate, colorectal, liver
• leading causes of cancer death among women: lung, breast, colorectal (see risk factors for developing breast cancer)
The following list includes risk factors that may increase a woman's chance of getting breast cancer.
• Risk factors that cannot be changed
• Gender
• Aging
• Genetic risk factors, including BRCA1 and BRCA2 genes
• Having one first-degree relative, e.g., mother, sister, daughter, with breast cancer
• Personal history of breast cancer
• Race and ethnicity
• Caucasian women are slightly more likely to develop breast cancer than African-American women
• African-American women are more likely to die of breast cancer
• Dense breast tissue
• Certain benign breast conditions, e.g., fibrocystic disease, mastitis, benign tumors
• Women who started menstruating before the age of 12
• Women who went through menopause at a later age (after age 55)
• Previous chest radiation exposure
• Exposure to diethylstilbestrol (DES)
• Lifestyle-related factors and breast cancer risk
• Not having children, or having them later in life
• Recent oral contraceptive use
• Using post-menopausal hormone therapy, i.e., estrogen replacement therapy (EST)
• Not breast-feeding
• Use of alcohol (the American Cancer Society recommends that women limit their consumption of alcohol to no more than one
drink a day)
• Being overweight or obese
Lack of physical activity
• Factors with uncertain, controversial, or unproven effect on breast cancer risk
• High-fat diets
• Antiperspirants
• Bras
• Induced abortion
• Breast implants
• Environmental chemicals
• Tobacco smoke
• Working nights
• Warning signs: The seven warning signs of cancer (see below) and cancer screening recommendations
• Seven Warning Signs of Cancer - C.A.U.T.I.O.N
C = Change in bowel or bladder habits
A = A sore that does not heal
U = Unusual bleeding or discharge from any part of the body
T = Thickening or lump in the breast or elsewhere
I = Indigestion or difficulty swallowing
O = Obvious change in a wart or mole
N = Nagging cough or hoarseness

Diagnostics
• history and physical exam - depends on location of tumor
• radiographic studies, e.g., chest x-ray, mammogram
• biopsy: obtaining tissue for histological examination
• needle biopsy: aspiration of cells
• incisional biopsy: removal of a wedge of suspected tissue from a larger mass
• excisional biopsy: complete removal of entire lesion or mass
• staging biopsy: multiple needle or incisional biopsies of suspected metastasis
• sentinel lymph node biopsy (SLNB): to determine extent (stage) of cancer
• vacuum-assisted biopsy: vacuum-assisted tissue biopsy (ex: Mammotome breast biopsy)
• cytological studies, e.g., Papanicolaou's (Pap) smear
• proctoscopic examination, including guaiac for occult blood
• liver enzyme tests
• imaging - using computerized tomography (CT scan), magnetic resonance imaging (MRI)
• tumor markers - identifying biochemicals made and released by tumor cells, e.g., prostate-specific antigen (PSA),
carcinoembryonic antigen (CEA), alpha-fetoprotein

How Chemotherapy Treatments Are Delivered

topical oral sublingual

subcutaneous intramuscular intravenous

PICC line non-tunneled catheters tunneled catheters

intraventricular (ommaya
intraperitoneal (single use,
reservoir) & intrathecal (lumbar intra-arterial
Tenckhoff catheters, Port-a-cath)
puncture)

intravesicular (med given through intrapleural (chemo is inserted into a implantable (wafers with meds are
urinary catheter directly into the chest tube to control malignant implanted in former site of brain
bladder) pleural effusions) tumor to kill tumor cells)
•
•
• The information presented in the table is an overview of the recommended cancer screening tests based on gender and age
for asymptomatic individuals who are at average risk.
• Cancer
Name of Test Gender Age Recommendations
Screening

American Cancer Society, 2015

20 years and older Monthly

Breast self-examination 40-44 years - option to start Every 3 years

(BSE) & clinical breast annual breast cancer
Breast
exam (CBE) female screening with
Cancer
mammograms;
Mammography
45-54 years Annually

55 years and older Every 2 years

Colonoscopy
50 years and older Every 10 years

Colorectal
Flexible sigmoidoscopy male &
Cancer and 50 years and older Every 5 years
female
Polyps
Guaiac-based fecal
occult blood test
50 years and older Yearly tests
(gFOBT)

21; 21-29 years Every 3 years

Papanicolaou (Pap) test
Age 30-65, with 3 normal Every 5 years
Cervical and pelvic exam
female consecutive Pap test results
cancer
Pap test plus HPV test
Age 65 and older (if all
previous tests were normal) No testing

Endometrial
Endometrial tissue At menopause for both
(uterine) female Annually, if indicated
sample average and high risk women
cancer

Digital rectal exam &

Prostate prostate-specific Starting at age 50 years, Routine screening no
male
cancer antigen (PSA) blood discuss with HCP longer recommended
test

Age 20 years and older -

periodic health exams to
male & screen for cancers of the
General Cancer check-up Annually/periodic
female thyroid, oral cavity, skin,
lymph nodes, testes, and
ovaries

Treatment - based on stage and grade of tumor, treatment objective is to remove all traces of the cancerous tissue
• surgery - specific to site and type of malignancy
• chemotherapy - use of chemical agents in the treatment or control of the disease (adjuvant therapy)
• radiation therapy - destroys cancer cells, with minimal exposure of normal cells to the damaging effects of radiation
(adjuvant therapy)
• -external beam radiation (the source of the radiation is external to the client)
• -brachytherapy: the radiation source comes into direct, continuous contact with tumor tissues for a specific time
(the source of the radiation is within the client)
• unsealed radiation source - administration is by oral or intravenous route or by installation into a body cavity
• sealed radiation source - solid implant is implanted with the tumor target tissues
(see lesson 7: Reduction of Risk Potential for more information about radiation therapy)
• biologic therapy - typically used along with conventional cancer treatments (adjuvant therapy)
• immunotherapy - helps repair, stimulate or enhance the body's natural ability to fight cancer, including cancer vaccines,
interferons, and interleukin 2 treatments
• targeted therapy - non-chemotherapy drugs used to target cancer cells
• monoclonal antibodies: artificially produced antibodies that act against a particular antigen, including trastuzumab,
etanercept, infliximab, abciximab
• tyrosine kinase: inhibits growth of cancer cells, such gefitinib for lung cancer, lapatinib for breast cancer, and sunitinib for
renal cell carcinoma
• bone marrow transplantation
• stem cell transplantation
Nursing interventions
• monitor for effectiveness of all medications
• monitor vital signs
• monitor for post-operative surgical complications
• monitor intake and output
• monitor diagnostic tests and laboratory values, e.g., white blood cell and platelet counts
• monitor for fever, sore throat, unusual bleeding, or findings of infection
• common sites of infection: skin, respiratory and gastrointestinal tracts
• ensure frequent and thorough hand hygiene by client, family, staff
• administer chemotherapy as prescribed - usually only chemotherapy certified nurses can administer
• intravenous route is most commonly used
• dosing based on total body surface area (BSA), which requires a current and accurate height and weight
• have another RN double-check medication and dosage, both on the order sheet and with the drug itself
• prepare in air-vented space (biohazard cabinet area); wear gloves, gown, eye protection and mask when handling IV
medications
• carefully monitor for phlebitis and extravasation
• stop infusion and notify physician with extravasation
• treatment may include elevating the extremity, heat or ice application (dependent upon medication), injection of antidote into
site
monitor side effects of chemotherapy and treat as indicated
• fatigue
• assist client in self-care and mobility activities
• allow adequate rest periods during care
• alopecia
• nutrition
• assist client in selecting a well-balanced diet
• provide small, frequent meals (high calorie, high protein, high carbohydrate) that require less chewing (soft foods)
• provide protein supplements as prescribed
• loss of appetite may be the result of taste changes or a bitter taste in the mouth from medications
• nausea and vomiting
• administer antiemetics, e.g., ondansetron, several hours before chemotherapy and for 12 to 48 hours afterwards, as
prescribed
• delayed nausea and vomiting can occur 7 days post administration
• mucositis
• provide mouth rinses every 12 hours, e.g., saline or sodium bicarbonate and water, as prescribed
• offer complete mouth care before and after every meal; instruct client to use soft toothbrush and avoid dental floss
• administer topical anesthetic agents to mouth sores as prescribed
• avoid hard or spicy foods
• avoid use of alcohol- or glycerin-based mouthwashes or swabs
• skin changes
• use electric razor for shaving
• avoid rectal suppositories, enemas, and rectal thermometers
• myelosuppression: bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, platelets
• monitor lab values for neutropenia anemia and thrombocytopenia
• initiate neutropenic protocol if white blood cell count decreases
• monitor for petechiae, ecchymosis, bleeding of the gums, and nosebleeds (due to decreased platelet count)
• avoid intramuscular injections and venipunctures
• administer blood products for anemia as prescribed
• monitor for signs of anaphylactic reaction
• obtain allergy history
• administer test dose if prescribed by physician
• have emergency equipment and medications available
• most reactions occur within 15 minutes of starting the infusion
• interventions
• stop the medication
• maintain airway
• notify physician
• maintain IV access with 0.9% normal saline
• place client in supine position with feet elevated (unless contraindicated)
• administer prescribed medications, typically epinephrine, corticosteroid, and diphenhydramine
monitor side effects of radiation therapy and treat as indicated
• follow radiation safety protocol for implanted, sealed radiation source
• local skin changes
• gently wash irradiated area with warm water (with or without mild soap); use hand, not washcloth
• take care not to remove skin markings
• alopecia
• fatigue - most common side effect of radiation (see side effects of chemotherapy on previous page)
• altered sense of taste (see side effects of chemotherapy on previous page)
• monitor for complications of bone marrow transplantation (see also Infection Precautions for Bone Marrow
Transplant Recipients)
• failure to engraft
• graft-versus-host disease in allogeneic transplants - (cautiously) managed with immunosuppressive agents
• veno-occlusive disease - treat with fluids and supportive therapy
• support client and family
• listen to and discuss expected body image changes
• respect client lifestyle choices, religious and cultural preferences
• discuss potential effect of (irreversible) infertility
• discuss end-of-life and grief and loss issues
• initiate appropriate support and resource systems
SAFETY- RADIATION
Radiation exposure occurs in diagnostic x-rays and radiopharmaceuticals. Clients undergoing implant therapy will have a
sealed source of radioactive material (containing alpha or beta particles and/or gamma rays) placed inside a body cavity,
close to the tumor.

An example of a treatment that emits both gamma rays and beta particles includes radioactive iodine-131 (I-131); I-131 has a
half-life of 8 days. Gamma rays have properties like x-rays and present a potential external hazard (they are the most
penetrating type of radiation). Alpha particles, which occur naturally in the environment, can be stopped by your skin and
clothing.

To protect yourself, remember the three elements of radiation: time, distance, and shielding. Use these simple techniques to
reduce the hazards associated with gamma rays:
• Mark the client's room with appropriate signage
• Place client in a private room
• Place wristband on client indicating that the client is receiving internal radiation therapy
• Put on shoe covers and protective gloves before entering the client's room; remove equipment before exiting the room
• Wear gloves
• When handling secretions/excretions of a client receiving systemic isotopes; flush toilet twice
• When changing linens of clients receiving systemic isotopes
• Plan care to minimize time at the client's bedside
• Work quickly, but effectively and courteously
• Maintain the greatest distance possible from the client consistent with effective care
• Restrict care to a maximum of one (1) hour every eight (8) hours
• Prepare meal trays outside the room
• Position items within client's reach so as to facilitate as much self-care as possible
• Schedule only one radioactive client to a nurse at a time
• Ensure a long handled forceps and a lead container are in the client's room in case of implant dislodgement
• In the event that a source becomes dislodged, notify the Radiation Oncologist
• Do not attempt to handle the dislodged implant unless trained to do so
• Wear a film badge (such as a dosimeter) while caring for client to monitor exposure; have it checked per agency policy
• No pregnant nurses, visitors, or children should be allowed near the client
PRECAUTIONS- BONE MARROW TRANSPLANT
After discharge from the hospital, bone marrow recipients recover at home for two to four months and generally cannot return
to full-time work for up to six months after the transplant. The following is a list of precautions these individuals should take to
reduce their risk of infection.
Don'ts: list of things to minimize contact with or to avoid
• Avoid contact with school children
• Avoid crowded places, e.g., movie theaters, grocery stores, department stores
• Avoid contact with anyone with a communicable disease
• Minimize contact with pets
• Cats
• do not place the litter box in the kitchen, dining room or other area of the house where food is prepared or eaten
• someone else should be responsible for daily litter box cleaning for 6 months after the transplant
• Avoid contact with reptiles, ducklings, or chicks
• Avoid swimming pools or walking/wading/playing in recreational water for first year
• Avoid immunizations without physician's approval
• Prevent infections transmitted by direct contact and respiratory transmission
• Avoid gardening, mulching, raking, mowing, farming, or direct contact with soil and plants
• Prevent respiratory infections
• avoid close contact with people who have respiratory illnesses, e.g., cough, cold
• avoid crowded areas, e.g., movie theaters, grocery stores, department stores
• avoid construction sites
• avoid wood-burning fireplaces
• avoid the use of a room humidifier (due to water-harboring bacteria)
• Avoid restaurant food for first three months
• Avoid drinking well water, unless the water is tested more than twice a day for bacterial contamination
Do's: list of things to do
• Personal hygiene
• Wash hands with antimicrobial soap and warm water, use hand sanitizer when outside the home
• before eating
• before and after preparing food
• after touching pets or animals
• after sneezing, coughing, or blowing nose
• before and after any central venous catheter care or intravenous infusion
• before taking oral medications
• after touching soiled linens or clothes
• Brush teeth and gums
• Shower or bathe as usual; however, do not submerge central venous catheter under water
• Take prophylactic antibiotics
• Call the doctor if any of the following signs or symptoms occur:
• Cloudy or foul-smelling urine
• Cough with yellow or green sputum or a persistent, dry cough
• Diarrhea
• Exposure to varicella, strep throat, herpes, or mononucleosis
• Fever of 100 F (37.8 C) for allogeneic clients or 100.5 F (38.1 C) for autologous clients
• Lesions or white patches in the mouth or on the tongue
• Redness, swelling, tenderness, or drainage at the site of the central venous catheter
• Shortness of breath
• Sinus drainage, nasal congestion, headaches, or tenderness along the upper cheekbones
• Skin rash
• Sore throat, scratch throat, or pain when swallowing
• Sweats or chills
• Trouble urinating
• Vaginal discomfort, itching, or unusual discharge
• Note: individuals are not required to wear a mask when they go outside their homes, but some might feel "safer" wearing a
mask
  Cancer pain management
• Causes of cancer pain
• bone destruction
• obstruction of an organ
• compression of peripheral nerves
• infiltration or distention of tissue
• inflammation
• necrosis
• psychological factors, e.g., fear, anxiety
• The World Health Organization has developed a 3-tiered approach for treating cancer pain
• begin with nonopioid analgesics (aspirin, paracetamol) if pain occurs
• if pain persists or increases, administer mild opioids (codeine) for mild to moderate pain, along with adjuvant medications to
calm fears and anxiety
• strong opioids (morphine) should be administered if pain is still not relieved, along with adjuvant medications to calm fears
and anxiety
• Nonpharmacological techniques for pain relief include acupuncture, guided imagery, biofeedback, massage therapy, heat-
cold applications, mindfulness-based stress reduction, relaxation therapies, hypnosis
• Nursing care, related to pain
• assess client's pain; pain is what the client describes - do NOT under-medicate the cancer client who is in pain!
• monitor effectiveness of medication
• monitor for side effects of medication, e.g., respiratory depression related to narcotic administration

 Pediatric Oncology
• Overview
• Cardinal findings
• Unusual mass
• Pallor
• Sudden tendency to bruise
• Rapid, unexplained weight loss
• Change in vision or eye
• Recurrent fever
• Persistent headache, often with vomiting
• Change in balance or gait
• Childhood cancers can occur suddenly, without early symptoms
• Childhood cancers usually arise from noninherited mutations in genes of growing cells
• There are 12 major types of childhood cancers; leukemias and cancers of the brain and central nervous system account for
more than half of the new cases
• Childhood cancer is highly curable
• For all age children, the goal is to prevent fear and misunderstanding

Age appropriate diversional activities:

Toddler washable soft toys, appropriate cartoons, action toys (wagon, push toys)

Pre-school appropriate cartoons, washable stuffed doll, coloring books and crayons, action toys

Kindergarten appropriate cartoons or video games, coloring book and crayons, washable stuffed toys

appropriate cartoons or video games, coloring book and crayons, school work when appropriate,
School age
computer, beads for creating jewelry

Middle
computer or cell phone, appropriate video games, school work when appropriate
School

High School computer or cell phone, appropriate video games, school work when appropriate
 CANCER interventions:
C = Comfort
A = Altered body image
N = Nutrition
C = Chemotherapy
E = Evaluate response to medications
R = Respite for caretakers

A. Leukemias
• Definition: cancer of while blood cells
Etiology
• unrestricted proliferation of immature leukocytes crowd the bone marrow and flood the bloodstream; this interferes with
production of red blood cells and platelets, resulting in anemia and bleeding problems and increased risk of infection
• account for 25% of all childhood cancers
• types: most common is acute (rapidly developing); also chronic (slow developing)
• acute (rapidly developing) - most common
• acute lymphocytic leukemia (ALL) - usually found in children ages 2 to 8 years
• acute myelogenous leukemia (AML)
• chronic (slow developing)
• risks: associated with having received prior radiation or chemotherapy for other types of cancer, genetic disorders (Down
syndrome, Kleinfelter syndrome, Fanconi's anemia); genetic link
• symptoms caused by infiltration and replacement of any tissue of the body with non-functional leukemia cells
• highly vascular organs such as spleen and liver are most severely affected
• Findings: acute or insidious onset depending on type
• anemia, thrombocytopenia, infection, bleeding
• lymphadenopathy, hepatosplenomegaly, bone or joint pain
• meningeal irritation, i.e., irritable, lethargic, stiff neck
• Diagnostics
• history and physical findings
• peripheral blood smear
• bone marrow aspiration
• lumbar puncture
• Management
• combination chemotherapy to achieve a remission; intrathecal administration of methotrexate
• radiation with central nervous system involvement
• bone marrow transplant
• Nursing interventions
• prepare child and family for diagnostic procedures
• relieve discomfort
• monitor for infection, hemorrhage and anemia
• manage problems of drug side effects, i.e., nausea and vomiting, anorexia, mucosal ulceration, neuropathy, alopecia, moon
face
• provide nutritional snacks
• refer for needed services - financial or home care
• teaching points
• long term treatment plan
• multidisciplinary approach
• bone marrow aspiration precautions
• encourage parents to ask questions when unsure
• school work for child when appropriate
REMEMBER: Children, particularly toddlers and preschoolers, tend to have bruises as a result of play. Any unusual bruising,
especially on the back or neck and/or large or dark bruises, must be checked out. It could be the first sign of leukemia or it
could possibly due to child abuse. If you are unsure, ask another nurse to assess the child with you.

B. Hodgkin's disease (Hodgkin's lymphoma)

• Definition: malignancy of the lymph tissue found in the lymph nodes, spleen, liver, and bone marrow
• Etiology
• neoplasm of lymphatic system
• characterized by giant, multinucleated cells (Reed-Sternberg cells)
• Findings
• characterized by painless enlargement of lymph nodes, particularly in supraclavicular area
• anorexia, weight loss, malaise; painless; night sweats
• fever
• Diagnostics
• lymphangiography
• labs: complete blood count (CBC), erythrocyte sedimentation rate, urinalysis, kidney function tests, protein levels, liver
enzyme tests
• bone marrow biopsy
• CT scan of the chest, abdomen, pelvis
• chest x-ray
• PET scan
• Management
• chemotherapy and radiation
• treatment based on staging of disease and age of client
• transfusion of blood products (platelets for low platelet counts or packed cells for anemia)
• antibiotics
• Nursing Interventions
• prepare for diagnostic procedures
• explain side effects of treatment
• provide age appropriate diversional activities
• refer to appropriate resources if sterility may result from radiation and/or chemotherapy
• teaching points
• long term treatment plan
• multidisciplinary approach
• encourage to ask questions when unsure
• school work for child when appropriate
• Possible Complications
• prognosis: most curable form of cancer
• long term complications of chemotherapy or radiation therapy

C. Brain tumors
• Definition: solid tumors of the nervous system
• Etiology
• types: medulloblastoma, astrocytoma, ependymoma, glioblastoma
• most common solid tumor in children
• location extremely important
• Findings
• headache
• vomiting
• ataxia
• seizures
• visual changes, slurred speech, behavioral changes
• bulging fontanel in infants
• Diagnostics
• history and physical, neurological exam
• MRI scan and CT scan of the brain
• bone scan
• myelogram
• lumbar puncture
• Management
• surgery
• adjuvant therapy: radiation and chemotherapy
• steroids, anti-seizure medication
• ventriculoperitoneal shunt
• possibly bone marrow transplantation
• Nursing interventions
• monitor neurologic checks and other neurologic sign changes
• assess and monitor vital signs
• prepare child and family for diagnostic and operative procedures; possible shaving of head
• positioning considerations depend on procedure done
• monitor dressing and intracranial pressure (ICP), if appropriate
• begin feeding when ordered
• medicate for discomfort as indicated
• teaching points
• child's post operative appearance
• refer for needed resources, including rehabilitation
• explain the procedure to the child based on developmental level, e.g., dolls for illustration of positioning, and procedure;
drawings for older children
• Complications
• prognosis: varies greatly
• late effects may include cognitive delay, seizures, growth abnormalities, hormone deficiencies, vision and hearing problems
• children who had brain tumors are more likely to develop a second cancer, including a second brain tumor

D. Neuroblastoma
• Definition: malignant tumor the develops from nerve tissue
• Etiology: unknown
• most common extracranial solid tumor of childhood
• accounts for almost all cases of cancer under age 1 year
• develops from tissues that form the sympathetic nervous system
• most neuroblastomas begin in the abdomen (in the adrenal gland or next to the spinal cord) or in the chest - can spread to
the bones, bone marrow, liver, lymph nodes, skin and around the eyes
• often has metastasized by the time it is diagnosed
• Findings: first symptoms are usually fever, malaise and pain; other findings are tumor-dependent
• enlarged abdomen - from tumor or excess fluid
• periorbital edema, cyanosis - cancer spread to eye(s)
• bone pain or tenderness - cancer spread to bones
• dyspnea or chronic cough - cancer spread to lungs/chest
• flushed red skin
• tachycardia
• profuse sweating
• Diagnostics
• physical exam - examination of abdomen may reveal a lump, swollen lymph nodes
• bone scan, x-rays
• CT and MRI scan of chest and abdomen
• biopsy
• labs: complete blood count (anemia), coagulation studies (ESR), hormone tests (especially epinephrine and other
catecholamines), 24-hour urine (for catecholamines, homovanillic acid and vanillylmandelic acid)
• Management: depends on tumor location, metastasis and client's age
• ranges from observation only in certain types of neuroblastoma to aggressive therapy with surgery, radiation therapy,
chemotherapy, and stem-cell transplantation for older children
• retinoid therapy, tumor vaccines and immunotherapy (using monoclonal antibodies)
• Nursing intervention: support family and encourage participation in support groups and counseling
• Complications
• prognosis: varies greatly
• metastasis and associated damage and loss of function of involved organ(s)
• children treated for neuroblastoma may be at risk for getting a second, different cancer in the future

E. Osteosarcoma
• Definition: malignant bone tumor that usually develops during a period of rapid growth (adolescence, young adulthood)
Etiology: unknown
• usually affects teens and people in their 20s
• originates from bone-forming mesenchyme
• location - most common in distal femur, also in the tibia or humerus
• may be a genetic link (gene associated with retinoblastoma)
• Findings: localized pain, limp, decrease in physical activity
• Diagnostics
• history, physical assessment
• bone scans, x-ray
• chest x-ray, CT scan of the chest - for suspected metastasis to chest
• Management
• surgery - limb salvage with prosthetic bone replacement or amputation
• chemotherapy before and/or after surgery
• Nursing interventions
• client and family support following amputation
• client and family teaching about stump care (see prosthesis prep.)
• referral to necessary resources for prosthetics, rehabilitation, support and counseling
 • Complications
• prognosis: long-term survival is good if cancer has not spread to lungs
• limb removal
• metastasis
• side effects of chemotherapy

F. Ewing sarcoma
• Definition: a rare malignant bone tumor affecting children
• Etiology: unknown
• arises not from osteoid tissue but in bone marrow spaces
• most common in shaft of femur, tibia, humerus, scapula
• more common in males and Caucasian children
• can occur any time but usually develops during puberty
• Findings
• few symptoms
• localized pain, decrease in physical activity
• pathologic fracture at site of the tumor
• Diagnostics
• biopsy, MRI, x-ray of tumor
• bone scan
• chest x-ray, CT of chest
• Management
• intensive radiation therapy of the malignant bone
• combined with chemotherapy
• cyclophosphamide
• doxorubicin
• etoposide
• ifosfamide
• vincristine
• after course of chemotherapy and possibly radiation, tumors may be removed surgically; amputation may be the only choice
• Nursing interventions
• assess client's and family's physical and emotional status
• client and family education
• encourage participation in support groups and counseling
• provide nursing care for client undergoing chemotherapy and radiation therapy
• Complications
• treatments have many complications and should be discussed on individual basis
• amputation has short- and long-term side effects

G. Wilms' tumor (nephroblastoma)

• Definition: a rare type of kidney cancer that affects children
• Etiology
• causes a tumor on one or both kidneys (more common on left kidney)
• most often affects children under age 5 years
• risks: certain genetic conditions or birth defects (hypospadias, undescended testicles, aniridia); family history; female; African
American
• tumor encapsulated for extended period
• Findings
• abdominal mass and swelling
• characteristically firm, non-tender
• constipation
• malaise
• high blood pressure
• increased growth on one side of body
Diagnostics
• abdominal ultrasound, x-ray
• intravenous pyelogram
• bone scans
• labs: blood urea nitrogen, complete blood count (may show anemia), creatinine and creatinine clearance, urinalysis
• do NOT prod or push on child's belly
• Management
• surgery - simple nephrectomy, partial nephrectomy, radical nephrectomy
• combination chemotherapy and radiation therapy
• Nursing interventions
• use care during bathing and handling to avoid injury to tumor site
• support family
• encourage genetic counseling
• treat effects of radiation and chemotherapy - nausea and vomiting, loss of appetite, mouth sores, fatigue, loss of hair,
weakened immune system
• teaching - tell parents to check with health care provider before any vaccinations
• Complications
• prognosis: 90% cure rate if tumor has not spread
• hypertension
• kidney damage

H. Rhabdomyosarcoma
• Definition: a malignant tumor of the muscles attached to bones; the most common soft tissue tumor in children
• Etiology: unknown
• soft tissue neoplasm
• grows from undifferentiated mesenchymal cells of skeletal muscle
• location: most common in head and neck, the urogenital tract, arms or legs
• may be a genetic factor
• highly malignant; often metastasized when diagnosed
• Findings
• non-tender, firm mass
• related to site of tumor and compression of adjacent organs
• symptoms often vague, similar to otitis media or "runny nose"
• Management: depends on the site and type of rhabdomyosarcoma
• surgery
• high-dose irradiation of the primary tumor
• combination chemotherapy
• surgical resection
• Nursing intervention
• pain management, including administration of pain medication, positioning, age-appropriate diversional activities
• encourage family participation in support group and counseling
• Complications
• prognosis: usually good
• complications from chemotherapy
• metastasis

I. Retinoblastoma
• Definition: a rare, cancerous tumor of the retina
• Etiology:
• caused by a mutation in a gene controlling cell division
• may have a genetic link
• generally affects children under the age of 6 years
• Findings:
• may affect one or both eyes
• differing iris colors in each eye
• leukocoria ("cat's eye reflex") - unusual whiteness noticeable in photographs taken with a flash
• strabismus, poor vision, double vision
• eye pain and redness
• Diagnostics
• ophthalmoscopic exam under general anesthesia,
• MRI and CT scan of the head
• head and eye echoencephalogram (ultrasound of the eye)
• Management: treatment depends on stage of tumor with grading
• laser surgery or cryotherapy - small tumors
• radiation therapy - local tumor or larger tumors
• chemotherapy - if tumor has spread beyond the eye(s)
• enucleation
• Nursing interventions
• assess child for this when parents report a strange light in the child's eye
• involve parents in care and teach about diagnostic procedures
• genetic counseling for parents
• multi-disciplinary support for child following enucleation of an eye
• teaching points: care for prosthetic eye
• Complications
• prognosis: if the cancer has not spread beyond the eye, almost all clients can be cured
• blindness

 Circulatory System Oncology

• A. Non-Hodgkin's lymphoma (NHL)
• Definition: cancer of the lymphocytes found in lymphoid tissue, which includes lymph nodes, spleen, and other organs of the
immune system
• Etiology: unknown
• both B lymphocytes and T lymphocytes can develop into lymphoma cells (B-cell lymphomas are more common in the U.S.)
• risk factors: adults with weakened immune systems or who have had an organ transplant
• types: based on how fast it spreads and by protein (B lymphocytes) and/or genetic markers (T lymphocytes)
• slightly more common in women
• Findings: many are dependent upon the location of the cancer (chest, abdomen, brain)
• painless, enlarged lymph nodes in cervical or axillary region
• night sweats, fever
• itching
• weight loss
• Diagnostics
• physical exam - enlarged lymph nodes
• biopsy of suspected tissue (usually lymph node)
• bone marrow biopsy
• labs: complete blood count, protein levels, liver enzyme tests, kidney function and uric acid level
• Management: depends on type of lymphoma, stage of the cancer, age and overall health of client, symptoms
• chemotherapy - main type of treatment
• radiation - for disease confined to one body area
• radioimmunotherapy may be used
• bone marrow transplant (using client's stem cells) - when chemotherapy is ineffective or lymphoma returns
• immunologic therapy: rituximab, a monoclonal antibody
• Nursing interventions - see Oncology Overview for more specifics
• encourage participation in support group and/or counseling
• client teaching: oral care, preventing infections during chemotherapy; self care of central line or PICC line; diet
• Complications
• prognosis: dependent on 5 factors - client's age, stage of lymphoma, organs affected outside the lymph system, ability to
perform ADLs, serum level of lactate dehydrogenase (which goes up with amount of lymphoma in the body)
• autoimmune hemolytic anemia
• infection
• side effects of chemotherapy drugs

 Respiratory System Oncology

• A. Cancer of the larynx
• Etiology
• most tumors of the larynx are squamous cell carcinoma
• more common among men, age 50 to 65 years-old
• risk factors include cigarette smoking and alcohol consumption
• Findings
• persistent sore throat
• dyspnea
• dysphagia
• increasing persistent hoarseness
• weight loss
• enlarged cervical lymph nodes
• neck pain/lump in neck (late)
• Diagnostics
• physical exam - may detect lump on outside aspect of neck
• other tests: biopsy, chest x-ray, CT scan of chest, head and/or neck, MRI of head or neck
• Management
• either surgery or radiation therapy alone - when tumor is small
• chemotherapy, along with radiation - when tumor is larger or has spread to lymph nodes
• surgery: removal of all or part of larynx (laryngectomy)
• brachytherapy
• Nursing interventions - see Oncology Overview for more specifics
• arrange for clients with laryngectomies to meet with members of support groups
• establish a method for communication before surgery to use after surgery
• maintain airway; have suction equipment at bedside
• observe for signs of hemorrhage or infection
• teach about tracheostomy and stoma care
• assist with period of grieving
• coordinate nutritional support
• Complications
• prognosis: throat cancers can be cured in 90% of clients if detected early
• possible airway obstruction
• difficulty swallowing
• disfigurement of the neck or face
• loss of voice and speaking ability
• metastasis

B. Lung cancer
• Etiology
• types of lung cancer
• squamous cell carcinoma
• small-cell (oat cell) carcinoma
• adenocarcinoma
• large cell carcinoma
• prognosis is generally poor
• largely preventable if smokers stop and nonsmokers avoid second hand smoke
Lung cancers are also known as bronchogenic carcinomas
• Classifications
• a. Small cell lung cancers (SCLC) - sometimes call "oat cell carcinomas"
• account for about 20% of lung cancers
• most aggressive and rapidly growing of all lung cancers
• strongly related to cigarette smoking
• metastasize rapidly
• b. Non-small cell lung cancers (NSCLC)
• most common of all lung cancers
• three main types:
• adenocarcinomas
• squamous cell carcinomas
• large cell carcinomas
• Treatment of lung cancer depends on the cancer stage and the client's overall health
• Stage 0
• tumor spread is limited to the surface of the bronchus (carcinoma in situ)
• treatment options: surgical resection (removal) and photodynamic (laser) therapy
• Stages I and II
• treatment is typically tumor removal surgery
• when surgery is not an option, options include radiation therapy, with or without chemotherapy
• Stages IIIA and IIIB
• treatment generally includes chest radiation combined with chemotherapy
• Stage IV
• treatment never involves surgery
• chemotherapy is the main treatment option; sometimes with radiation therapy
• Surgery options
• Mediastinoscopy - minimally invasive; used to sample the lymph nodes along the main airway
• Thoracoscopy - minimally invasive; also called video-assisted thoracic surgery (VATS)
• Wedge resection - removing a small section of one lung
• Segmentectomy - removing a segment of one lung
• Lobectomy - removing an entire lobe of one lung
• Sleeve resection - removing a part of the airway
• Pneumonectomy - removing a lung
 Comparison of Lung Cancers
Non-Small Cell Lung Cancer (NSCLC)

Large Cell Squamous Cell

Carcinoma(al Carcinoma(also Small Cell Lung
Type of Cancer
so called called Epidermoid Cancer (SCLC)
Adenocarcinoma
Undifferentia Carcinoma)
ted
Carcinoma)

• NOT related to • Cigarette smoking

• Cigarette • (Almost always)
cigarette smoking • Exposure to
smoking cigarette smoking
• Lung scarring environmental
Risk Factors • Environmental • Environmental
• Chronic interstitial carcinogens, e.g.,
carcinogens carcinogens
fibrosis uranium, asbestos

• Accounts for 30-

35% of NSCLC
cases
• The most common • Least
• Most common type
among women common type
of NSCLC
• Accounts for about of NSCLC • Accounts for about 20%
• The most common
50% of NSCLC • Frequently of lung cancers
type of lung cancer
• Found in the glands metastases • Cells multiply quickly
in men
of the lungs that via blood and form large tumors
• Findings occur
produce mucus • This cancer that can spread
Characteristics earlier because of
• Arise in the outer, or forms near the throughout the body
bronchial obstructive
peripheral, areas of surface (or • Very malignant form
characteristics
the lungs outer edges) • Often associated with
(arises from
• Often no clinical of the lungs endocrine disturbances
bronchial epithelium)
signs or findings • Can grow
• Causes cavitating
until well advanced rapidly
pulmonary lesions
• Usually
metastasizes locally

• Usually client
is not a • Poorest prognosis
candidate for • Median survival time
surgery due to without treatment is 2 to
• Does not respond
the high • Life expectancy is 4 months
well to
frequency of better than small cell • Most responsive to
chemotherapy
Therapy/ metastasis carcinoma radiation therapy and
• Most often, surgical
Treatment • Tumors often • Surgical resection is chemotherapy; brain
resection is
respond to often attempted radiation treatment may
attempted
radiation be used to prevent the
therapy but spread of cancer to that
frequently area
recur

Findings
• hoarse voice
• changes in breathing
• persistent cough or change in cough
• blood-streaked or bloody sputum
• chest pain or tightness in chest wall
• recurring pneumonia, pleural effusion
• weight loss
• Diagnostics
• medical imaging examinations
• cytological sputum analysis, carcinoembryonic antigen (CEA) test, complete blood count, liver enzyme tests and kidney
function tests
• bronchoscopy
• biopsy
Management
• nonsurgical
• adjuvant therapy: chemotherapy and radiation therapy
• biological therapies, including monoclonal antibodies (especially angiogenesis inhibitors), interferons, interleukins, colony-
stimulating factors, vaccines, gene therapy and nonspecific immunomodulating agents
• laser therapy to de-bulk tumor
• thoracentesis and pleurodesis
• surgical: thoracotomy
• wedge resection - part of a lobe
• segmental resection- part of a lobe
• lobectomy - one or more lobes
• pneumonectomy - entire right or left lung
• Nursing interventions - see Oncology Overview for more specifics
• maintain chest drainage system
• provide routine post operative care
• monitor respiratory status frequently
• teach effective deep breathing and cough techniques
• refer to physical therapy for exercises for shoulder on affected side
• relieve pain
• optimize oxygenation
• provide opportunities for the client to talk about cancer; as needed, refer to support groups
• teach information as based on treatment plan and prognosis
• optimize nutritional status

 Neurological System Oncology

• A. Brain tumors
• Definition: growth of tissue within skull
• may be cancerous or benign
• classified according to tissue type
• may be primary or metastatic
Findings
• increased intracranial pressure
• depend on size and location of tumor
• frontal lobe: personality changes, focal seizures, visual disturbances, hemiparesis, aphasia
• occipital lobe: focal seizures, visual hallucinations
• temporal lobe: seizures, headache
• parietal lobe: seizures, visual losses
• cerebellum: coordination or walking/mobility difficulties
Diagnostics
• history and physical exam
• computerized tomogram (CT) scan
• magnetic resonance imaging (MRI)
• Management
• goals are to remove the tumor and minimize harm to the nervous system
• depends on location and size of tumor
• treatment for increased intracranial pressure
• surgery
• craniotomy to remove tumor
• stereotactic laser surgery
• radiation therapy for malignancy
• pharmacologic: chemotherapy (for malignant tumors)
• Nursing interventions - see Oncology Overview for more specifics
• care of the client with increased intracranial pressure
• care of the client undergoing surgery
• seizure precautions
• seizure care
• good nutrition and fluid balance
• emotional support
• care of the client undergoing radiation therapy
• care of the client undergoing chemotherapy

 Gastrointestinal
• A. Colon cancer
• Definition: the development of malignant cells in the epithelium of the large intestine
• Etiology
• may develop from adenomatous polyps
• risk factors: low residue diet, high-fat diet, refined foods, age over 50 years, history of polyps of the colon and/or rectum,
family history, inflammatory bowel disease, exposure to carcinogens
• Pathophysiology
• adenocarcinoma is the most common type
• most common locations are sigmoid rectum and ascending colon
• often metastasizes to the liver
• Findings
• rectal bleeding
• change in bowel habits - constipation, diarrhea
• change in shape of stool
• anorexia and weight loss
• abdominal pain, palpable mass
Diagnostics
• colonoscopy
• sigmoidoscopy
• digital examination
• stool for occult blood, complete blood count, liver enzyme tests, carcinoembryonic antigen (CEA) test
• barium enema
• CT scan
• carcinoembryonic antigen (CEA)
• Complications - obstruction, perforation of the bowel wall by the tumor, metastasis
• Management
• radiation
• chemotherapy
• local excision and fulguration (small, localized polypoid lesions)
• treatment of choice is surgery - bowel resection, colostomy
• right hemicolectomy - involves ascending colon
• left hemicolectomy - involves descending colon
• abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy
Nursing interventions - see Oncology Overview for more specifics
• manage pain
• monitor for complications
• wound infection
• atelectasis
• thrombophlebitis
• maintain fluid and electrolyte balance
• care of ostomy
 B. Liver Cancer (hepatocellular carcinoma)
• Definition: cancer of the liver
• Etiology
• the cause of liver cancer is usually scarring of the liver (cirrhosis), due to alcohol abuse, hepatitis B or C virus infection,
autoimmune diseases of the liver, hemochromatosis
• occurs more often in men
• usually seen in people older than age 50
• Findings
• abdominal pain or tenderness (upper right quadrant)
• easy bruising or bleeding
• enlarged abdomen
• fatigue
• jaundice
• Diagnostics
• abdominal CT scan, ultrasound, MRI
• liver biopsy
• laparoscopy
• chest x-ray - to determine if the liver tumor is primary or has metastasized from a primary tumor in the lungs
• liver enzymes, serum alpha fetoprotein, serum bilirubin
• Management
• surgery or liver transplant - best for treating small or slow-growing tumors
• chemotherapy
• radiation treatments
• sorafenib tosylate: blocks tumor growth
• prevention: childhood vaccination against hepatitis B
• immunosuppressive drugs - following liver transplant
• tacrolimus
• cyclosporine
• sirolimus
• mycophenolate mofetil (MMF)
• corticosteroids
• azathioprine
• muromonab-CD3 or OKT3
• thymoglobulin
• IL-2 Receptor Antagonist Antibodies
Nursing interventions - see Oncology Overview for more specifics
• encourage participation in support groups
• encourage discussion of end-of-life wishes and efforts to improve quality of life
• overview of post op care following liver transplant
• respiratory status - care of client on ventilator
• care for intravenous lines (peripheral and arterial)
• care for drains/tubes, including Jackson-Pratt, T-tube, nasogastric, indwelling urinary catheter
• have emergency equipment nearby, e.g., crash cart, Level 1 rapid infuser
• monitor neurologic status
• renal status - monitor BUN, creatinine; also intake and output
• integumentary status - care for incision/dressing (abdominal binder may be used), care for pruritus with topical lotions,
position to reduce risk of skin breakdown
• gastrointestinal status
• assess for ileus, re-bleeding from preexisting varices, diarrhea, signs of acute abdomen
• monitor nutritional status - hyperalimentation, tube feeding
• monitor for signs of infection and rejection (which may occur simultaneously) - fever, decreased quantity/quality of bile,
change in liver enzyme test results, malaise, increased ascites
• care for end stage liver disease (ESLD)
• monitor labs - fluid and electrolyte imbalances, platelet counts, serum ammonia
• low protein diet
• assist with ambulation, range of motion due to muscle weakness, stiffness
• monitor for bleeding, stool for occult blood, hemoglobin and hematocrit
• monitor breathing and elevate head of bed
• monitor intake and output
• monitor for encephalopathy - neurologic signs
• monitor for indications of renal failure
• monitor skin for breakdown and apply lotion - pruritus is common
• administer diuretics for ascites and care for client undergoing paracentesis
• monitor and treat nausea and vomiting
• prevent or manage constipation
• assist with pain management
• Complications
• poor prognosis
• gastrointestinal bleeding, liver failure, metastasis to other parts of the body

C. Pancreatic Cancer
• Definition: cancer of the pancreas
• Etiology: unknown
• more common in people with diabetes, chronic pancreatitis, smokers
• may be genetic link
• Findings - often go undetected until the cancer is advanced
• in the head of the pancreas: weight loss, jaundice, dark urine, clay-colored stools, itching, abdominal pain, back pain
• in the body or tail of the pancreas: abdominal and/or back pain, weight loss
• Diagnostics
• CT and MRI of the abdomen
• endoscopic retrograde cholangiopancreatography (ERCP)
• endoscopic ultrasound
• pancreatic biopsy
• labs: complete blood count, liver enzyme tests, serum bilirubin, carcinoembryonic antigen (CEA) test
• Management
• surgery - pancreaticoduodenectomy (Whipple procedure)
• may be done but usually cancer is so advanced that surgery is often not successful
• involves removing the head of the pancreas, gallbladder, part of the duodenum, the pylorus, the lymph nodes near the head
of the pancreas
• radiation therapy or chemotherapy - when the tumor has not spread out of the pancreas but cannot be removed
• Nursing interventions - see Oncology Overview for more specifics
• pain management
• palliative care
• manage complications of Whipple procedure - delayed gastric emptying and other digestive difficulties
• Complications
• very poor prognosis
• common complications: blood clots, depression, infection, liver problems, pain, weight loss

 Genitourinary System Oncology

• A. Bladder cancer (urothelial cancer)
• Definition: cancer that starts in the bladder (from the transitional cells lining the bladder)
• Etiology: unknown; possibly cigarette smoking, exposure to chemicals, family history
• Findings
• hematuria - most common sign
• pain - in the flank, above the pubic bone or in the perineum
• dysuria
• Diagnostics
• imaging tests: intravenous pyelogram, CT
• cystoscopy
• urinalysis and urine cytology
• Management
• a. stage 0 and I
• surgery to remove the tumor without removing the bladder - usually a transurethral resection of the bladder (TURB)
• chemotherapy
• immunotherapy: usually the Bacille Calmette-Guerin vaccine (BCG) or interferon given directly into the bladder using an
indwelling urinary catheter
• b. stage II and III
• surgery to remove part of or entire bladder
• cystectomy - remove bladder
• ileal conduit, continent urinary reservoir, or orthotopic neobladder surgery may be performed to help drain urine after the
bladder is removed
• chemotherapy and radiation therapy either before (to shrink tumor) and/or after surgery
• c. stage IV
• no surgery
• chemotherapy may be considered - inserting agents doxorubicin HCl, valrubicin and epirubicin
• palliative care
• d. laser-ablation therapy
• Nursing interventions - see Oncology Overview for more specifics
• palliative care
• encourage participation in support groups and counseling
• support change in body image following urinary diversion surgery
• support clients with changes to their sexuality
• Complications
• prognosis depends on the stage of cancer
• anemia
• urinary incontinence
• urethral stricture

B. Cancer of the kidneys

• Definition: a type of kidney cancer that starts in the lining of the kidney tubules
• Etiology
• renal cell carcinoma - most common type of kidney cancer
• risk factors: smoking, hypertension, obesity, family history, chronic kidney failure and/or dialysis, high calorie diet, Von Hippel-
Lindau disease
• more common in men, detected between the ages of 50 and 70 years
• Findings: unknown
• may be asymptomatic
• abdominal, back, flank pain
• hematuria
• varicocele (swelling of the veins around a testicle)
• weight loss
• sometimes excessive hair growth in females
• Diagnostics: no blood or urine tests to directly detect the presence of tumors
• kidney ultrasound, MRI or CT scan
• renal arteriography
• intravenous pyelogram (IVP)
• labs: complete blood count, liver enzyme tests, urinalysis
• tests used to determine metastasis: abdominal CT, MRI; bone scan; chest x-ray, PET scan
• Management
• surgery: partial or radical nephrectomy (radical nephrectomy includes removal of kidney and adrenal gland)
• tumor ablation - cryoablation (freezing malignant cells) or microwave ablation (extreme heat)
• arterial embolization - to shrink tumor
• hormone treatments
• chemotherapy
• immunotherapy
• multikinase inhibitors: sorafenib, sunitinib, temsirolimus
• angiogenesis inhibitor: bevacizumab
• radiation therapy usually does not work for kidney cancer
• Nursing interventions - see Oncology Overview for more specifics
• encourage participation in support groups and counseling
• assess remaining kidney function
• teaching: healthy lifestyle choices include exercise and well-balanced diet high in fiber and low in animal fat, quit smoking
• palliative care (if indicated)
• Complications
• prognosis depends on tumor stage and grade
• hypertension
• hypercalcemia
• high red blood cell count
• liver problems
• metastasis (kidney cancer spreads easily)

C. Female oncology
• 1. Cervical cancer
• three types dysplasia
• dysplasia
• carcinoma in situ
• invasive carcinoma
etiology and epidemiology
• the most common age group is 35 to 55 years of age
• higher incidence in African American women
• higher incidence among low socioeconomic populations
• risk factors include
• multiple sexual partners
• human papillomavirus (HPV)
• history of sexually transmitted diseases
• sexual activity at an early age
• prevention: HPV vaccine Gardasil╟ - a series of 3 injections over 6 months to be completed before becoming
sexually active
findings
• usually asymptomatic in early stages
• postcoital bleeding, irregular vaginal bleeding
• spotting between periods
• spotting after menopause
• evidence of discharge
• pain with radiation to buttocks and legs
• anemia
• weight loss
• fever
• diagnostics
• Papanicolaou test (Pap smear)
• staging laparotomy
metastatic evaluation
• intravenous urography (also called intravenous pyelography [IVP])
• cystoscopy
• sigmoidoscopy
management
• radiotherapy
• used in any stage
• internal - radium via applicator
• external - via linear accelerator or cobalt
• surgery
• hysterectomy
• not commonly recommended for women of childbearing age
• if carcinoma in situ or invasive carcinoma, combine with radiotherapy
• complication: impairment of the bladder function is most commonly found
• pelvic exenteration (removal of all organs in the pelvis - bladder, uterus, ovaries, colon, etc.)
• conization
• chemotherapy - used in addition to surgery or radiation when indicated
• nursing interventions - see Oncology Overview for more specifics
• assess
• history of pap smears, sexual history and past sexually transmitted diseases
• presence of vaginal bleeding, discharge, weight loss, leg pain, flank pain
• client's understanding of the disease
• reduce anxiety
• enhance body image
• complications include metastasis to
• lungs
• mediastinum
• bones
liver with subsequent spread to rectum and bladder
 2. Endometrial cancer
• definition: cancer that starts in the endometrium, the lining of the uterus
• etiology: unknown
• the most common type of uterine cancer
• may be related to increased levels of estrogen
• most cases occur between the ages of 60 and 70 years old
• risk factors: estrogen replacement therapy without the use of progesterone, history of endometrial polyps, infertility or never
being pregnant, use of tamoxifen (for breast cancer), menopause after age 50
• findings
• abnormal bleeding from vagina, i.e., bleeding between periods, spotting after menopause
• extremely long, heavy, or frequent episodes of vaginal bleeding after age 40
• thin white or clear vaginal discharge after menopause
• diagnostics
• endometrial aspiration or biopsy
• dilation and curettage (D & C)
• pap smear
• management
• surgery - (abdominal) hysterectomy
• radiation therapy and chemotherapy
• nursing interventions - see Oncology Overview for more specifics
• post operative care: pain control, and assess for increased bleeding (hemorrhage)
• encourage participation in support group
• client teaching: encourage frequent pelvic examinations and screening tests, e.g., Pap smear

*Look Good... Feel Better is dedicated to improving the self-esteem and quality of life of people undergoing treatment for
cancer.

3. Breast cancer
• definition: cancer that starts in the tissues of the breast types of breast cancer
• etiology
• in women, may begin in lining of milk duct or the lobes
• higher risk if family history
• risk may increase with the use of hormones
• types
• invasive (infiltrating): spreading outside the membrane that lines a duct or lobule, invading the surrounding tissues
• noninvasive (in situ) - includes ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS)
• findings
• painless, firm lump - most often immoveable
• painless thickening in a breast
• enlargement of axillary nodes or supraclavicular nodes
• nipple discharge
• scaliness or retraction of nipple (seen more in Paget's disease)
• pain, ulceration, edema, orange-peel skin (usually late finding)
diagnostics
• Mammography
• biopsy or aspiration (stereotactic biopsy, Mammotome╟ or vacuum-assisted biopsy, ultrasound-guided biopsy, ductal lavage)
• tumor cell tests
• tests to determine metastases (bone scan, MRI, CT scan)
• labs: tumor marker tests, including carcinoembryonic antigen (CEA) test, CA15.3, TRU-QUANT, CA125
• management
• surgical approach (will depend on the results from the lymph node biopsies and tumor staging) - from most
conservative to radical
• lumpectomy - tumor removal and small amount of normal tissue around it
• partial mastectomy - removal of part of breast with cancer and some surrounding tissue
• total mastectomy - removal of whole breast
• modified radical mastectomy - removal of whole breast, many of the lymph nodes, the lining over the chest muscles
• radical mastectomy - removal of whole breast, all of the lymph nodes, chest wall muscles
• radiation therapy
• chemotherapy
• cyclophosphamide
• methotrexate
• doxorubicin HCL
• paclitaxel
• endocrine therapy
• bone marrow transplant
• oophorectomy
• adrenalectomy
• hormone therapy
• tamoxifen: for premenopausal women with positive nodes or stage 1 with negative nodes
• to block the effects of estrogen
• the course of treatment is commonly a minimum of two years; may continue with tamoxifen or started with exemestane or
raloxifene for 3 more years depending on hormonal levels in the breast
• exemestane or raloxifene: for post menopausal women
• use of other hormones in advanced disease
• estrogens (DES) or ethinyl estradiol to suppress FSH and LH
• progestins may decrease estrogen receptors
• androgens may suppress FSH and estrogen production
• aminoglutethimide blocks estrogen by blocking adrenal steroids
• corticosteroids from the adrenal glands suppress secretion of estrogen and progesterone
complications of breast cancer
• metastases
• bone pain, neurologic changes, weight loss, anemia
• shortness of breath, cough, pleuritic pain, nonspecific chest discomfort
• nursing interventions - see Oncology Overview for more specifics
• obtain a health history
• identify the type of education needed
• evaluate the level of anxiety and fear
• determine the levels of coping abilities
• refer available support systems to
• reduce anxiety
• provide education
• enhance coping strategies
• assess for lymphedema and nerve damage following a radical or modified radical mastectomy (when lymph nodes are
removed)

D. Male oncology
• 1. Breast cancer in males
• cancer resembles the types found in women
• a greater incidence in men in their 60's
• accounts for about 1% of all breast cancer cases
• prognosis is poor because men delay seeking diagnosis and treatment
• gynecomastia is often an associated factor
2. Prostate cancer
• definition: malignant neoplasm, usually adenocarcinoma, of prostate gland
• etiology and epidemiology
• more prevalent in African American men
• most appear on the peripheral zone of the gland
• most are palpable on rectal examination
• spreads via the lymphatics, the bloodstream or by local extension
• specific etiology unknown; familial history increases risk
• findings
• usually asymptomatic in early stages
• obstruction of urinary flow that may result in urinary urgency, hesitancy, dribbling, retention, nocturia, infection, hematuria
• pain in an area represents the location of the metastases
• lumbosacral
• hips
• lower legs
• rectal discomfort
• weight loss
• anemia
• edema of the lower extremities
• diagnostics
• digital rectal examination
• needle biopsy of the gland
• transrectal ultrasonography
• descending urography
• serologic markers
• prostate specific antigen (PSA)
• prostatic acid phosphatase
• metastatic evaluations
• chest x-ray
• intravenous urography (also called intravenous pyelography or IVP)
• CT scan of specific areas or entire body
• MRI
management
• conservative approach
• usually no treatment for men over 70 due to the prostate cancer's slow progression
• analgesics to manage pain - both non-narcotic and narcotic
• short course of radiation therapy (site-specific)
• administration of IV strontium chloride 89 (beta emitter agent)
• placement of suprapubic catheter for obstructed outflow through urinary tract
• surgical approach
• radical prostatectomy
• laparoscopic dissection of pelvic lymph node
• cryosurgery
• transurethral resection of prostate (TURP)
• curative approach
• external beam radiation
• interstitial radiation - the direct implantation of radioactive substances into the prostate either permanently (seeding) or briefly
(high dose rate); also called brachytherapy, seed implantation
• palliative approach
• hormone manipulation
• estrogen therapy diethylstilbestrol (DES)
• luteinizing hormone-releasing hormone (LHRH)
• bilateral orchiectomy (removal of the testes)
• use of anti-androgen drugs
• flutamide - blocks the effect of testosterone
• drugs are often used in combination therapy
nursing interventions - see Oncology Overview for more specifics
• assess
• presence of urinary urgency, hesitancy, dribbling, retention, nocturia, infection, hematuria
• presence of palpable lymph nodes
• presence of flank pain, weight loss, rectal pain
• presence of bladder distention
• control pain to acceptable levels
• reduce anxiety in clients and family members by referrals
• discuss potential changes re: sexual functioning, energy levels
• complications
• of the cancer - bone metastases
• of hormone manipulation
• nausea and vomiting
• gynecomastia
• sexual dysfunction
• hot flashes

 Endocrine System Oncology

• A. Thyroid cancer
• Etiology
• radiation exposure increases risk for thyroid malignancies
• thyroid malignancy is rare in the U.S. (benign thyroid disease is relatively common)
• most thyroid tumors are benign
• most common types: papillary and follicular
• greater likelihood of malignancy in clients older than age 60 years and younger than 30 years-old
• Findings: painless, palpable, solitary nodule on thyroid gland
• Diagnostics
• history and physical (palpation of nodule)
• fine needle aspiration biopsy (FNAB)
• ultrasound of the thyroid, thyroid scan
• laryngoscopy
• serum thyroid-stimulating hormone (low), calcitonin
• Management
• surgical excision - total or subtotal thyroidectomy
• postoperative radioiodine scanning and ablation
• RapidArc radiotherapy: a fast and precise form of radiation therapy
• possibly chemotherapy
• medications
• thyroid hormone replacement therapy - usually T4 or triiodothyronine
• recombinant human TSH - in remnant ablation
• Nursing interventions - see Oncology Overview for more specifics
• support clients undergoing radioisotope treatment
• post-operative care: relieve pain, observe for indications of tracheal obstruction, swelling, bleeding or laryngeal spasm
• Complications
• injury to the larynx and hoarseness after thyroid surgery
• low calcium levels from accidental removal of parathyroid glands
• metastasis

 Integumentary System Oncology

• A. Melanoma
• Definition: malignant tumors that originate in the pigment-producing melanocytes in the basal layer of the epidermis
Etiology
• fair skin, blue or green eyes, or red or blond hair
• live in sunny climates or at high altitudes
• have had one or more blistering sunburns during childhood
• use tanning devices
• genetic predisposition
• Findings - identification of potentially malignant pigmented lesions
• A for asymmetry
• B for border irregularity
• C for color multiplicity
• D for diameter greater than 1/4 inch
• E for evolution (change) in size and/or shape

• Diagnostics
• epiluminescence microscopy (magnification and polarized light to enhance detection)
• biopsy
• sentinel lymph node biopsy - to predict progression of disease
Management - almost always curable if recognized and treated early
• excision of the tumor (stage 1)
• Mohs micrographic surgery - layers of tissue are removed until margins of skin are cancer-free
• regional lymph node dissection
• adjuvant treatment:
• radiation therapy
• immunotherapy/biochemotherapy, including interferon injections, tumor necrosis factor, lymphokines, and vaccines
• gene therapy
• chemical peeling
• laser therapy
• regional limb profusion (chemotherapy limited to an extremity) or chemotherapy
• photodynamic therapy
• peginterferon alfa-2b: used to treat stage III melanoma
Black Box Warning - can cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemias, and infectious
disorders; genotoxic
• Nursing interventions - see Oncology Overview for more specifics
• with radiation therapy, prepare client for common side effects such as nausea, vomiting, diarrhea, hair loss, malaise
• reduce anxiety
• anticipate need for analgesics
• patient and family teaching teaching
• how to recognize early signs of melanoma
• location of common sites of melanoma - back, legs, between toes, face, feet, scalp, fingernails and backs of hands
• avoid exposure to sun - wear long sleeves, hats and use sun block
• help control the odor of a wound with odor-masking essential oils such as oil of cloves or balsam of Peru

B. Nonmelanoma skin cancers - account for more than 90% of skin cancers
• 1. Basal cell carcinoma (BCC)

definition: abnormal, uncontrolled growths or lesions from the skin's basal cells (the deepest layer of the epidermis)
• etiology
• usually caused by a combination of cumulative UV exposure and intense, occasional UV exposure
• almost never metastasizes
• most common form of skin cancer
• finding: look like open sores, red patches, pink growths, shiny bumps, or scars
• management
• surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation, cryosurgery, photodynamic
therapy, laser surgery
• radiation
• topical medications
• imiquimod - for superficial BCC; works by stimulating the immune system
• 5-Fluorouracil (5-FU) - for superficial BCC
• vismodegib - for more advanced BCC
Black Box Warning - embryotoxic and teratogenic
• nursing interventions
• teaching about skin cancer prevention and identification
• supportive care for disfigurement

2. Squamous cell carcinoma

• definition: uncontrolled growth of abnormal cells arising in the squamous cells (upper layers of the epidermis)
etiology
• second most common form of skin cancer
• mainly caused by cumulative UV exposure over the course of a lifetime
• can be disfiguring and may be deadly if allowed to grow
• findings
• look like scaly red patches, open sores, elevated growths with central depression, or warts; may crust or bleed
• usually occurs on any area exposed to sun but may occur on mucous membranes and genitals
• management
• surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation, cryosurgery, photodynamic
therapy, laser surgery
• radiation
• topical medications: 5-Fluorouracil (5-FU)
• nursing interventions
• teaching about skin cancer prevention and identification
• supportive care for disfigurement

3. Actinic keratosis (also called solar keratoses): scaly or crusty growths (lesions) caused by damage
from UV light; the most common pre-cancer
4. Dysplastic nevi (atypical moles): unusual benign moles that resemble melanoma

POINTS TO REMEMBER
• Sarcomas are cancers that begin in connective or supportive tissue, e.g., bone, cartilage, fat or muscle. Lymphomas
and myelomas are cancers that begin in the cells of the immune system.
• This staging system signifies the extent or severity of a client's cancer. The T stands for the extent of the primary
tumor and N is for lymph node involvement. M for metastasis.
• Each monoclonal antibody recognizes only one particular protein, so different antibodies have to be used to target
different types of cancer. For example, trastuzumab (Herceptin╟) is used to treat certain breast cancers.
• Hodgkin disease is a malignancy of the of lymph tissue (found in the lymph nodes, spleen, liver and bone cancer).
(most curable form of cancer)
• This vaccine, which is given to adolescent boys and girls, can prevent diseases cause by the human papillomavirus
(HPV). This includes several different types of cancer and genital warts.
• The most common sites for melanoma in fair-skinned women (including fair-skinned Hispanics) are the lower legs
and upper back. For fair-skinned men, the most common site for melanoma is the upper back. Melanomas in dark-
skinned people often appear in the mouth, palms of the hands, soles of the feet and under the nails.
• Most colon polyps are benign growths. But some growths can turn into colon cancer. Polyps found during a
colonoscopy can be removed and examined.
• Childhood cancers, if diagnosed and treated early, are highly curable.
• Lung cancer is the leading cause of cancer deaths in women in the U.S. and Canada.
• Using high-energy radiation, the DNA of the cancer cells is damaged and the cell will die. X-rays, gamma rays and
charged particles are types of radiation used for cancer treatment. Internal radiation therapy (brachytherapy) is
another treatment for cancer.
• Clients undergoing chemotherapy should avoid crowds and persons with infections and to report signs of infection.
• Radiation has local effects related to site irradiated; chemotherapy is more systemic.
• Biological therapies (interferons, interleukins, colony-stimulating factors, monoclonal antibodies, vaccines, gene
therapy, and nonspecific immunomodulating agents) use the body's immune system to fight cancer or to lessen the
side effects that may be caused by some cancer treatments.
• Although clients receiving internal radiation are not radioactive, the implant or injection is radioactive; treat waste
products and body fluids as radioactive.
• Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of
cancer.
• Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal antibodies, especially
infliximab, since they will allow TB to fulminate.
• Melanoma is the most dangerous form of skin cancer and the leading cause of death from skin disease.
• Lung cancer is the leading cause of cancer deaths in both men and women (exception - the leading cause of cancer
deaths in Hispanic women is breast cancer).
• Most pancreatic cancer has a very poor prognosis since it's often advanced when first discovered.
• The cause of liver cancer is cirrhosis, which may occurs with hepatitis B or C. Everyone should be vaccinated for
HBV; the Centers for Disease Control and Prevention recommends that all "baby boomers" are tested for HCV.
• Administration of human papillomavirus 9-valent vaccine, recombinant (Gardasil╟9) is recommended for both boys
and girls.
• There are 12 major types of childhood cancers; leukemias and cancers of the brain and central nervous system
account for more than half of the new cases.
• Children typically have longer treatment plans than adults due to their increased metabolic rate and rate of cell
turnover.
• Cure rate is improving for most types of pediatric malignancies.
• During nursing assessment of a child with Wilms' tumor, do NOT palpate the abdomen
• Neuroblastoma is a cancer that actually begins in utero.
• An active child who suddenly becomes lethargic and exhibits symptoms of childhood cancer, e.g., weight loss, pain,
and fever, should be evaluated by a health care provider.
• Acute leukemia can advance very quickly; a child with anemia and bruising should be evaluated for leukemia.
• Osteosarcoma is more common than Ewing's sarcoma but both are tumors of the bone.
• Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena cava syndrome, septic shock.
• Pediatric cancer is a highly charged emotional arena. Be calm and collected in dealing with both parents and clients.
• All cancer victims and their families need support and encouragement.