ONCOLOGY

Sir Lianmuel De Guzman

CANCER
WHAT: Abnormal cell transformation
WHY: Genetic mutation of cellular DNA (genetic makeup of the cell, it dictates function, structure of the cell)

FACTOR NORMAL CANCER (malignant)

CYTOPLASM (cell wall) LARGE (definite and regular shape)
SMALL (indefinite and irregular shape)
NUCLEI/NUCLEOLUS SINGLE (one DNA) MULTIPLE (multiple DNA = erratic
(house of the DNA) function)
CELL DIVISION LIMITED (Apoptosis: programmed RAPID (NO apoptosis)
cell death)
CELL DIFFERENTIATION = YES NO
function
MIOTIC CELL DIVISION 2 DAUGHTER CELLS MULTIPLE DAUGHTER CELLS
FUNCTION SPECIFIC NO FUNCTION/WORSENS
Goblet cells: mucus and cough *SIADH = sobra ADH, small ihi = FVE
production *Pheochromocytoma = tumor at
adrenal medulla > ↑ catecholamines =
HTN crisis

TYPES OF CANCER
A. NEOPLASIA: NEW GROWTH
B. NEOPLASM: NEW VASCULARIZATION (tumor and cancer can create their own blood vessel network)
cancer can create their own blood vessel network
• Artery: get O2 and nutrients
• Vein: remove waste products
causes cancer cells to thrive longer

BENIGN MALIGNANT
ENCAPSULATED (with borders) NON-CAPSULATED
NON-METASTATIC METASTATIC new onset of distant pain = metastasis
MAY CAUSE DEATH USUALLY CAUSES DEATH (higher chances of death)
*Laryngeal tumor = airway obstruction due to multiple organ failure
WITH BORDERS BORDERLESS

*Patient is diagnosed with small lung cancer. Patient develops distended jugular vein, crackles, HTN, and
tachycardia. What is the priority nursing action?
1. Increase sodium in the diet
2. Promote fluid intake
3. Assess level of consciousness
4. Assess ADH levels
Cancer with symptoms of congestion = check for possibility of SIADH (metastasis cancer to the pituitary
gland)
 WHO IS YOUR PRIORITY PATIENT?
1. Laryngeal cancer patient with wheezes and DOB = expected
2. Bladder cancer with painless hematuria
3. Kidney cancer with new onset of chest pain = metastasis
4. Testicular cancer with severe scrotal pain
PAIN = priority symptom (highly subjective = report of pain)

METASTASIS: ability to spread

LYMPHATIC HEMATOGENOUS
Tumor enters lymph channel through the interstitial Via bloodstream (immune system present here)
fluid Natural killer cells (specialized T cells) – activated by
laughter
Lodges in the lymph node (satellite center of *cancer = camouflage
immunity, waste management) Attracts fibrin, platelets, and clotting factors to look
like self
Impairs immune system responses Looks like self to avoid immune system surveillance

NURSING RESPONSIBILITIES:
A. Primary – promote and prevent!
• Focused on health teaching
RISK FACTORS:
I. NON MODIFIABLE
• Genetic (dominant (one gene to manifest) vs recessive (2 genes to manifest) trait)
• Age
a. Breast cancer: 40 and above
b. Testicular cancer: 15-35 years old
c. Cervical cancer: 20-40 years old
d. Prostate cancer: 50 and above
• Gender
a. Breast cancer: female > male
b. Testicular, Prostate cancer: male
• Race: AFRICAN AMERICAN (higher cancer growth, respond lesser to chemo drugs)

II. MODIFIABLE
A. PHYSICAL
• Chronic inflammation (chronic esophagitis – Barrett’s esophagus = cancer)
• Chronic IBD (colon cancer)
• Sunlight (Caucasians > African American)
B. CHEMICAL
• Smoking, alcohol, asbestos (shipbuilding), silica (miners), chlorofluorocarbons (hair products,
aerosol, freon), asphalt, wood and cement dust, paint thinner
 C. DIET
• High fat, low fiber diet (colon cancer), preservatives, processed, smoked
D. LIFESTYLE
• Stress (manage stress), sedentary (active: 20-30 mins/day)
E. BACTERIA/VIRUS
• H. Pylori (peptic ulcer = gastric cancer)
• HPV (cervical cancer)
• HIV (decrease immune system)
• Epstein Barr virus/Kissing Disease (self-limiting: chronic complication = lymphoma)

HEALTH TEACHING:
WARNING SIGNS OF CANCER
Change in bowel/bladder habits
• Colon cancer = alternating constipation and diarrhea, pencil shaped stool (thin stool = tumor
causes obstruction) = early symptom
o Melena – dark red bleeding, black tarry stool, old blood = upper GIT bleed
o Hematochezia – bright red bleeding, fresh blood = lower GIT bleed
• Bladder cancer = painless hematuria
(If painful hematuria = renal stones; pain mgt: fluids & ambulate)
(larger stones = extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy)
• Prostate cancer (obstruction of urinary flow > incomplete bladder emptying) = dribbling urine
(balisawsaw; decrease force of urine flow but with increase urgency and frequency to void), nocturia
A sore that doesn’t heal
• Sore that took 2 months to heal = NOT CANCEROUS
*mouth sore/stomatitis – lasts for more than 14 days = report to dentist
Unusual bleeding/discharge
• Clear drainage at the nipples = CANCEROUS
Thickening/lumps
• Painless lump at testicles = report (any shape, painless or not)
• Breast cancer = lump at upper outer region
Indigestion/Dysphagia
• Indigestion (gastric cancer)
• Dysphagia (esophageal cancer, laryngeal cancer)
Obvious change in wart/mole
• Mole – Melanoma = report mole: growing, irregular borders, asymmetrical color and structure
• Wart – basal cell carcinoma
Nagging coughing/Hoarseness (laryngeal cancer)
• Dry cough = NOT CANCEROUS
Unexpected anemia
• Related to internal bleeding
Sudden weight loss
• Tumor/cancer steals glucose
PET Scan (Positron Emission Test) – can detect clusters of tumor cells that metastasized
• Positron = rich in glucose (glucose concentrates on the tumor)
• Nuclear medicine

SCREENING TESTS
BREAST CANCER
A. Self-breast examination = more convenient; circular (outer to inner), pinch nipples
o Males: Advised if taking pills (check every month, before opening a new pack)
o Females with menstruation: 7-10 days post menstruation
o Irregular menstruation/menopause: same day of each month (birthday or first day of the
month)
• Wedge method (OB) = more accurate test

B. Clinical breast examination = OB

• 20-39 years old = every 3 years
• 40 and above = every year

C. Mammogram = with painless option

• For 30-35 years old = baseline
• 40-49 years old
o If high risk (estrogen – early menarche, late menopause (pills); genetics) = every year
o If low risk = every 2 years
o 50 years old and above = every year
Nursing considerations:
• Orient there would be some discomfort
• NO deodorant, NO talcum powder before test

CERVICAL CANCER
• PAP SMEAR = every 3 years
o PAP SMEAR SOLUTION – positive if with white spots upon inspection = for biopsy
o Sexually Active = within 3 years of sexual contact
example: 14 y/o first sex = 17 y/o first pap smear
o Not sexually active = 20 years old and above
• Virgin = TRANSRECTAL

TESTICULAR CANCER (15-35 years old)

• Testicular Self-Exam
o 13 years old – every month after warm bath
o Dark room with penlight – light goes through cyst, outline tumor
PROSTATE CANCER (accessible via rectum)
• Digital rectal examination
o One finger only, gloved and lubricated -
upward
*If downwards = check colon cancer
o Sim’s position = left side lying with knees
flexed (to straighten colon)
o For 40 years old above = every year
• Prostate Specific Antigen (blood test)
o 50 years old and above = every year
o NORMAL PSA: below 3.0

Palliative care and hospice focused on comfort and dignified death (respect patient’s autonomy)
• Palliative – active management of discomfort (allow meds)
• Hospice care – focuses non-pharmacological management

DIAGNOSTICS
• BIOPSY (DEFINITIVE) – determine of malignant or benign
o Incisional: part of tumor
o Excisional: full tumor
o Needle aspiration (Fine Needle Aspiration): liver, breast, spleen, bone marrow
(posterior iliac crest/sternum) = FLAT BONE – least invasive = faster recovery
▪ Flat bone – RED bone marrow = stem cells
*Hip fracture = bleeding
▪ Long bone – YELLOW bone marrow
less than 21 years old = RED bone marrow
*Long bone fracture = risk for fat embolism
(Sx of embolism)
- cerebral embolism – ALOC
- cardiac embolism – chest pain
- pulmonary embolism – rashes/petechiae at the chest

* Patient is for biopsy this 8:00. Which of the following statements requires further assessment?
1. Pt took a breakfast at 6:00 with green leafy salad and chicken chops (okay lang)
2. Patient PT results is 12.5s (normal PT: 11-12.5 seconds)
3. Pt is taking Apixaban (-xaban = Xa inhibitors = anticoagulant – prevents clots) – risk for BLEEDING!
4. Pt is taking Acetaminophen for pain (okay lang)
BIOPSY: priority = BLEEDING!!!
Nursing considerations (BIOPSY):
Focus: RISK FOR BLEEDING
1. AVOID THE FOLLOWING:
• AVOID anticoagulants
o -xaban
o heparin (IV)/enoxaparin (SQ) – fast acting
o coumadin/warfarin (ORAL) – slow acting
• AVOID antiplatelet (aspirin, clopidogrel)
• AVOID thrombolytics (dissolve clot) = urokinase, streptokinase, alteplase, T-PA (tissue plasminogen
activator)
2. CHECK BLEEDING PARAMETERS = PT, PTT, INR
3. POSITION DURING BIOPSY: Unaffected side (expose the affected)
• Liver biopsy = left side-lying (expose right for access)
4. POSITION AFTER BIOPSY: AFFECTED = promote pressure and prevent bleeding
• Post liver biopsy = right side-lying
5. POST BIOPSY
• WOF bleeding!!!
if present apply pressure for 5-10 minutes

TREATMENT MODALITIES
1. CHEMOTHERAPY
• Kills of inhibits production of neoplastic cells but also kills normal cells
o Priority of RN when handling chemo drugs?
a. Perform sterile technique
b. Wear gloves
c. Check for compatibility to IV fluid
d. Check baseline levels of WBC
• Systemic effect. Usually affects:
SIDE EFFECTS: expected = manage
a. Skin = dryness; chemo drug = vesicant solution (irritating to the vein = EXTRAVASATION)
o Extravasation (best sx: skin sloughing)
▪ diluted, use bigger veins (more blood = better dilution), away from the joint
b. GIT
nausea and vomiting
o antiemetic: metoclopramide, ondansetron
o dry crackers, ginger
peptic ulcer
o avoid gastric irritants
o give antacids/PPI
stomatitis
o avoid hot and acidic food
o warm saline gargles or chlorhexidine; avoid commercial mouthwash (alcohol)
 c. Hair
o Alopecia (temporary; up to post 3-6 months from last session); grows back but lesser quality
Management: wigs, scarf, hat, cap
d. Sperm, Egg = destroyed by chemotherapy
o Sperm/egg banking = before chemotherapy (upon diagnosis is made)
e. Hematopoietic cells
o bone marrow suppression = all decreased: RBC, WBC (priority), Platelet (Pancytopenia)
o P.I.N.A
Positive pressure = immunocompromised
Negative pressure = airborne

TYPES OF CHEMOTHERAPY
A. CELL CYCLE SPECIFIC
• Anti-Metabolites – 5Fluoracil, Methotrexate, 6mercaptopurine
• Vinca Alkaloids – Vincristine, Vinblastine
B. NON CELL CYCLE SPECIFIC
• Alkylating – busulfan, cisplatin, carboplatin
• Nitrosoureas – lomustine, carmustine
• Antineoplastic antibiotic – bleomycin, infliximab
C. TYROSINE-KINASE INHIBITORS
• Estrogen (diethyl stilbesterol) = TESTICULAR CANCER
• Antiestrogen (anastrozole, tamoxifen) = BREAST CANCER
• Antiandrogen (FLJUTAMIDE)
• Progentin (megesterol acetate) - PROGESTERONE

* Patient is taking Cisplatin. Priority assessment to report to doctor?

a. chest pain
b. DOB
c. Ear pain
d. bone pain
e. leg pain
Cisplatin – nephrotoxic, ototoxic

* Patient is taking chemotherapy for the first time. Upon arrival of the pt to the medsurg unit, what is the
priority assessment to report?
a. Bruises and petechiae (expected – dec platelet levels)
b. Mouth sores (expected)
c. Prolonged QRS interval (hyperkalemia)
d. Painful urination (increase uric acid levels – stone)
e. Elevated phosphate levels (tumor lysis syndrome)
f. Low calcium levels (tumor lysis syndrome)
TUMOR LYSIS SYNDROME
• Related to rapid destruction/lysis of tumor
• Byproduct tumor destruction:
o Potassium = hyperkalemia
o Uric acid = hyperuricemia (gout, stones)
o Phosphate = hyperphosphatemia, hypocalcemia
• PREVENTION:
o Divide chemo into sessions

ADVERSE EFFECTS OF CHEMOTHERAPY

• Cisplatin/carboplatin – ototoxicity (ear pain, tinnitus, vertigo)
o Nephrotoxic (monitor BUN and creatinine, flank pain)
• Bleomycin – lung fibrosis (DOB, SOB)
• Doxorubicin – cardiotoxicity, cardiomyopathy, ECG changes (chest pain)
o Monitor Troponin I and CKMB
• 5-FU – gastric toxicity (peptic ulcer), peripheral neuropathy (paresthesia:
tingling sensation, numbness at extremities)
• 6-mercaptopurine – hepatotoxic (jaundice)
o Monitor ALT, AST, SGPT/SGOT
• Cyclophosphamide – hemorrhagic cystitis (suprapubic pain, bladder
distention, hematuria)
• Vincristine – peripheral neuropathy (paresthesia)
• Methotrexate – Myelosuppression (marrow suppression = pancytopenia)

2. RADIATION
BITE
• BRACHYTHERAPY = INTERNAL RADIATION = patient radioactive
a. Sealed: implant = risk for dislodgement
Management:
▪ bedrest without bathroom privileges
▪ avoid straining
▪ stool softeners (docusate)
▪ avoid forceful coughing/sneezing – antihistamine
▪ if dislodged: one pair of gloves, long forceps, lead container
▪ if unseen: call RadTech
b. Unsealed: IV or oral-secretions radioactive
▪ Flush toilet 2-3x
▪ Wash utensils 2-3x
 Focus: patient is radioactive (radiation burns
1. SHIELD = lead apron, dosimeter – badge that measures radiation (everyone that enter the room =
HCW, visitor)
2. DISTANCE = 6ft away
3. TIME = 5 mins/exposure, 30 mins/shift/day
4. SAVE BED LINENS = separate washing
5. NOT ALLOWED TO VISIT: pregnant, geria, children, immunocompromised

• TELETHERAPY = EXTERNAL RADIATION = patient is NOT RADIOACTIVE

o Focus of care: skin integrity (radiation burns)
Nursing considerations:
• WOF: skin injury
• DO NOT remove skin marker
• NO sun exposure, NO extremes of temperature (hot/cold)
• Loose soft clothing, cotton (ideal material)
• AVOID wool, silk, jeans, tight fitting clothes, buckles, straps, belt
• DIET (promote wound healing: Vitamin C, protein
• Wash area with water, mild soap (use hands)
• Dry: use wash cloth – path dry

PROSTATE CANCER
• Male 50 years old and above
• History of STD or HIV
• High cholesterol levels
• BPH DOES NOT lead to prostate cancer
BPH – related aging process for males
• Consequence: urinary obstruction; urine retention = post renal failure
Priority: FLUID BALANCE
• Dx test: Digital rectal exam, Prostate specific antigen (normal: less than 3.0)
• Early sx: dribbling urine, nocturia, increase frequency and urgency to void, incomplete bladder
emptying = bladder distention
• Late sx: renal failure, UTI, stones
• Sx of metastasis = new onset of distant pain

Management: RADIATION/CHEMOTHERAPY
• Prostatectomy
a. Radical prostatectomy = with incision via the rectum
o Slower recovery
b. TURP (transurethral resection of the prostate gland) = NO incision
o Faster recovery
 o Complication (post-TURP): bladder clots and bleeding
Management: CYSOCLYSIS/CONTINUOUS BLADDER IRRIGATION

CYSOCLYSIS/CONTINUOUS BLADDER IRRIGATION

• It prevents clots and bleeding post TURP
• 3-way foley catheter (inflow, outflow, anchor-balloon)
• Priority management: PATENCY!!!
Sx of non-patency:
o Bladder distention = priority
o Decrease/sluggish output
o Urge to void
o Suprapubic pain
• Irrigant = PNSS (isotonic) (prevent water toxicity FVE related to bladder water re-absorption)
• Normal output first 24 hours = pinkish red
Doctor’s order: increase flow rate
• Normal post 24 hours = clear
D.O: decrease flow rate

CERVICAL CANCER
• Females
• HPV – unsafe sex
• Multiple sex partners
• Early pregnancy
• Genetics
• Smoking
• Consequence: bleeding – shock
• Early sx: Asymptomatic (thick whitish drainage, no odor post sex)
• Late sx: dark malodorous drainage post sex (necrotic cervical tissue), dyspareunia (painful sex),
bleeding post sex
• Sx of metastasis = new onset of distant pain
• Dx test: PAP SMEAR WITH BIOPSY
• Management: RADIATION, CHEMOTHERAPY, CRYOSURGERY (freezing points to remove CA)
HYSTERECTOMY (removal of uterus = infertility)
Alternate Sx = CONIZATION (remove cervix) WITH CERCLAGE – SHRIRODKAR/MCDONALDS

BREAST CANCER
• Estrogen – early menarche, late menopausal, pills, genetic, smoking
• Consequence: sepsis – shock
• Early sx: thickening/lumps, unusual discharge at nipples
• Late sx: painful lumps, asymmetrical breast, breast heaviness, peau de orange with dimpling
• Sx of metastasis = new onset of distant pain
 • Dx test: MAMMOGRAM WITH BIOPSY
• Management: RADIATION, CHEMOTHERAPY
MASTECTOMY
a. Simple – remove breast tissue only (nipples, areola, pectoralis, axillary, and cervical lymph nodes
= intact)
b. Radical – remove everything
c. Modified radical – cervical lymph nodes remain intact
Nursing considerations: POST MASTECTOMY
BP and other procedures at unaffected side
Record Jackson pratt (drain every shift) = normal: <100 ml/hr
Elevate affected arm above the heart level to prevent lymphedema
Avoid abduction and external rotation of affected arm (allow simple flexion and extension)
Self-breast exam on another breast
To promote positive self image