Oncology

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Immunity! Antigens vs. Antibodies

● Antigen
○ Protein marker on the outside of the cell
○ Marks “self” vs. “other”
○ Tells the body what belongs
○ Tells the body what to attack
● Antibody
○ Produced specifically for one antigen
○ Locks on like a key
○ Attacks cell

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 The Immune System

When things go wrong….

● Cells start dividing uncontrollably
● They may spread (metastasize) into other tissue
● The body’s immune system doesn’t flag them like it should
○ Their growth continues on unchecked

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Terminology
● Benign - not cancerous
● Malignant - cancerous
● Blasts - Immature white blood cells
● Lymphoid - tissue that makes lymphocytes; lymph tissue
● Myeloid - tissue of the bone marrow
● -lymphoma - arises from the lymphoid tissue
● -myeloma - arises from the myeloid tissue
● -carcinoma - arises from the surface, or epithelium
● -sarcoma - arises from the connective tissue

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Chemotherapy
● Causes immunosuppression
○ Destroys cancer cells
○ Stops cancer cell growth
○ Prevents cancer cells from metastasizing
● But….this destroys healthy cells too!

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Chemotherapy side effects
● Anemia
○ Fatigue
● Thrombocytopenia
○ Bleeding risk
● Neutropenia
○ Immunosuppression
○ High infection risk
● GI upset
○ Loss of appetite
○ Nausea
○ Vomiting

Chemotherapy precautions
● Chemo is administered by nurses with specialized training
○ Administered with special gloves and PPE
● Oral chemo at home
○ Only the client and caregiver should handle the medication
○ Wash your hands before and after handling the medication
○ Wear gloves while handling
○ If the medication spills, clean the spill right away
○ If the medication gets on the skin, wash and rinse using soap and water right away
● Bodily fluids
○ Handle anything soiled with bodily fluids with care
○ Clean up any spills right away
○ Wash anything soiled with bodily fluids separately

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Radiation
● High energy directed at cancer cells to shrink and kill them
○ X-rays
○ Gamma-rays
● Forms of radiation
○ External - machine directs beams of radiation at location of tumor
○ Internal - radioactive material placed in the body near the cancer cells
■ Brachytherapy
■ The body may give off a small amount of radiation for a short time

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External Radiation Precautions

Internal Radiation Precautions

● Wash your laundry separately from the rest of the household, including towels and sheets.
● Sit down when using the toilet (both men and women) to avoid splashing of body waste.
● Flush the toilet twice after each use, and wash your hands well after using the toilet.
● Use separate utensils and towels.
● Drink extra fluids to flush the radioactive material out of your body.
● No kissing or sexual contact (often for at least a week).
● Keep a distance away from others in your household.
● Avoid contact with infants, children, and women who are pregnant.
● Avoid contact with pets.
● Avoid public transportation.
● Plan to stay home from work, school, and other activities.

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Specific
Cancers

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Leukemia
● A malignant progressive disease in which the bone marrow produces
increased numbers of immature or abnormal leukocytes. These suppress the
production of normal blood cells, leading to anemia and other symptoms.
● “Blood cancer”

Pathophysiology
● Abundance of blasts
● These underdeveloped cells can’t function
● Immunity is suppressed since these immature WBCs are not functioning
● Excessive blasts suppress the bone marrow
● Other cells in the blood begin to die due to the excess of blasts
○ RBCs → anemia
○ Platelets → inability to clot
○ WBCs → infection

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Classifications
● Acute Lymphocytic Leukemia (ALL)
○ The immature cells that the body is producing too many of are lymphoid cells.
○ Most common in 2 to 5 year olds
○ Treatable and more common
○ 85% survival rate.
● Acute Myelogenous Leukemia
○ The immature cells that the body is producing too many of are myeloid cells.
○ Poor outcomes
○ 27 % survival rate

Assessment Side effects of treatment

● Weight loss ● Infection
● Fever ● Bleeding
● Infections ● Nausea
● Arthralgia ● Vomiting
● Pallor ● Loss of appetite
● Fatigue ● Weight loss
● Bleeding ● Ulcers
● Bruising ● Alopecia

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Interventions
● Treatment
○ Chemotherapy
○ Steroids
○ Radiation
○ Bone marrow transplant
● Management
○ Neutropenic precautions
○ Antibiotics
○ Antiemetics
○ Enteral nutrition
○ Blood product administration

NCLEX Question
The nurse is taking vital signs on their client with a diagnosis of ALL. His
temperature is 38.7C. What is the nurse's first priority?

a. Place cool washcloths on the client's head

b. Continue with their assessment
c. Obtain intravenous access on the client
d. Assess the client's perfusion
e. Assist the client in taking oral antipyretics

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Answer: C
A is incorrect. Placing cool washcloths on the client's head is not the priority, there is a better answer. This would only need to be done if the client
was at risk for seizures due to an incredibly high body temperature. The temperature of 38.7C does not warrant cooling measures, and the nurse
has another immediate priority given the client’s immunosuppression and their suspicion of an infection.

B is incorrect. It is not appropriate for the nurse to simply continue with their assessment. They suspects an infection in their client who is
immunocompromised. Another answer has an immediate priority that the nurse must do.

C is correct. It is the priority action to establish intravenous access on this client. This client has a diagnosis of ALL, so the nurse knows that he is
immunocompromised. He is very susceptible to infections, and with a fever of 38.7C they have a high index of suspicion for an infection. Broad
spectrum IV antibiotics will need to be started right away, therefore it is the priority for the nurse to start an IV.

D is incorrect. Assessing the client's perfusion has nothing to do with the nurse’s suspicion of an infection. They should immediately establish IV
access for the administration of antibiotics.

E is incorrect. Assisting the client in taking oral antipyretics, such as acetaminophen or ibuprofen, may help to reduce the client's fever. However, in
a client with a diagnosis of Acute Lymphoblastic Leukemia (ALL) and a temperature of 38.7°C, simply administering oral antipyretics is not the
nurse's first priority. ALL is a type of cancer that affects the blood and bone marrow, and individuals with compromised immune systems are at
increased risk of infections. A fever in this context could be an indication of an underlying infection, which can be serious and potentially
life-threatening.
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Infection control and safety

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatrics
Lesson: Oncology

Lymphoma
● Cancer of the lymphatic system
● Affects the lymphocytes
● Impairs the body’s natural immune response

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 Classifications
● Hodgkin’s
○ Localized, single group of nodes
○ Reed-Sternberg cells are present
○ Extranodal involvement not
common
● Non-Hodgkin’s
○ Multiple lymph nodes are
involved
○ Reed-Sternberg cells are not
present
○ Extranodal involvement is
common
○ Most common type of lymphoma

Assessment
● Painless swelling of lymph nodes
● Fatigue
● Fever
● Night sweats
● Infections
● Weight loss
● Enlarged liver of spleen

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Interventions
● Treatment
○ Chemotherapy
○ Radiation
○ Bone marrow transplant
○ Immunotherapy
○ Lymph node removal
● Management
○ Neutropenic precautions
○ Antibiotics
○ Antiemetics
○ Enteral nutrition

Lung Cancer Signs and Symptoms

● Wheezing
● Cough
● Shortness of breath
● Hemoptysis
● Difficulty swallowing

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Lung Cancer Interventions
● Surgery
○ Wedge resection
○ Lobectomy
○ Pneumonectomy
● Radiation therapy
● Chemotherapy

● Cancer of the Esophagus

○ Most common at the gastroesophageal junction
○ Facilitated by chronic inflammation and dysplasia caused by gastroesophageal reflux and long-term exposure to
irritants (alcohol and tobacco)
○ Clinical manifestations
■ Chest pain and dysphagia
○ Treatment
■ Surgical removal, chemotherapy, radiation, stents
● Cancer of the Stomach
○ Environmental risk factors

■ Infection with Helicobacter pylori that carries the CagA gene product, cytotoxin-associated antigen A (80% of cases)

○ Dietary factors

■ High salt intake

■ Food additives (nitrates) in pickled or salted foods (bacon)

■ Low intake of fruits and vegetables

○ Atrophic gastritis

○ Lifestyle, alcohol consumption, cigarette smoking

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Breast Cancer
● Most common cancer in women
● Predisposing factors
○ Gender (females are at higher risk)
○ Age (+55 yrs)
○ Menopause
○ Genetics - BRCA1 AND BRCA2 genes

Symptoms
● Painless lump in the breast or underarm
● Flattening or indentation on the breast
● Change in the size, contour, texture of the breast
● Pitted surface like the skin of an orange
● A change in the nipple
○ Indrawn
○ Dimpled
● Unusual discharge from the nipple
○ Clear
○ Bloody
○ Any color

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Breast self exam
● Done monthly
● Should occur 3-7 days after
period ends
○ After menopause, pick a date
and do on that day each month

Treatments
● Lumpectomy
○ Removing the tumor from the breast
● Mastectomy
○ Removing the entire breast
● Radiation therapy
● Chemotherapy
● Hormone therapy
○ Tamoxifen

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Prostate Cancer
High risk clients:

● African-American males
● +60 y.o.
● Family history of prostate cancer
● Alcohol abuse
● High fat diet
● Farmers
● Painters

Screening
● Prostate Specific Antigen (PSA)
○ Blood test
● Digital Rectal Exams (DRE)
○ Done on men >40 y.o.

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Symptoms
● Slow start of urinary stream
● Dribbling of urine after starting stream
● Slow urinary stream
● Straining when urinating
● Urinary retention
● Blood in urine
● Bone pain
○ Often in low back and pelvis

Treatments
● Radical prostatectomy
○ Removal of the prostate
● Radiation therapy
● Chemotherapy
● Hormone therapy

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Testicular Cancer
Risk factors:

● Abnormal testicle development

● History of testicular cancer
● History of undescended testicle

Symptoms
● Testicular discomfort
● Heaviness in scrotum
● Lower abdominal pain
● Enlargement of the testicle
● Change in the way the testicle feels
● Gynecomastia
○ Excessive development of breast tissue
● Lump or swelling in testicle

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Treatments
● Orchiectomy
○ Removal of the testicle
● Radiation therapy
● Chemotherapy

Skin Cancers

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Squamous cell carcinoma
● Very top layer of the epidermis grow out of control
● Form on areas of the body exposed to sun
○ Face
○ Ears
○ Neck
● Treatment
○ Removal
● More likely to grow into deeper layers of the skin

Basal cell carcinoma

● Most common type of skin cancer
● Start in the basal cell layer (bottom layer) of the epidermis
● Form on areas of the body exposed to sun - head, face, neck
● Slow growing
● Rarely spread
● Treatments
● Surgery
● Local therapies
○ Cryotherapy
○ Photodynamic therapy (PDT)
○ Topical chemotherapy
○ Immune response modifiers
○ Laser surgery
○ Chemical peeling
● Radiation
● Chemotherapy
● Targeted therapy
● Immunotherapy

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Melanoma
● Melanocytes grow out of control
○ The cells that produce melanin
● Less common; more dangerous - can spread more easily
● Appearance: dark brown or black
○ The cells are making lots of melanin!
○ Most commonly located on trunk or legs
● Treatments
○ Surgery
○ Immunotherapy
○ Targeted therapy drugs
○ Chemotherapy
○ Radiation

Oncology
Pediatrics

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Wilms Tumor
The most common childhood kidney tumor
and a type of nephroblastoma

Assessment
● Physical assessment

○ Swelling or a palpable mass in the abdomen

○ Abdominal pain

○ Less common: hematuria, anemia, hypertension

● Imaging: ultrasound and/or CT scan

● Labs to check kidney function

● Biopsy

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Treatment
● Surgical - removal of the tumor and none/some/or all of affected kidney and
surrounding tissue

● Chemotherapy

● Radiation

Treatment will depend on tumor staging, which will likely be determined through
imaging and assessment

Acute Lymphocytic Leukemia (ALL)

● Most common pediatric cancer
● Quickly progressing blood cancer originating in the lymphocytes, which are a
type of white blood cell
● Begins in bone marrow → invades blood → spreads to other organs in body

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Assessment Findings
● Abnormal CBC - decreased hemoglobin and hematocrit, decreased platelets,
varying difference in white blood cells depending on clinical condition
● Fever, fatigue, pale skin, bruises, frequent/persistent infections
● Abnormal bleeding
● Weight loss
● Abdominal swelling
● Enlarged lymph nodes
● Bone or joint pain
● Positive bone marrow biopsy

Treatments and Interventions

● Infection prevention
● Platelet transfusions to reduce bleeding risk
● Dietary support
● Chemotherapy
● Stem cell or bone marrow transplant
● Clinical trials

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 Oncologic Emergencies

Tumor Lysis Syndrome

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Superior Vena Cava Syndrome

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