Cancer Nursing Care – Comprehensive Bullet‐Point Notes

Module Learning Outcomes

  • Safe & Effective Care Environment
    • Identify nursing interventions that enhance safety for cancer patients across the lifespan.
  • Health Promotion & Maintenance
    • Identify modifiable/non-modifiable cancer risk factors.
    • Describe the nurse’s role in prevention, early detection, & diagnostic screening.
  • Physiological Integrity
    • Outline the 3 stages of cancer development.
    • Apply the nursing process to assess, plan, implement, & evaluate individualized care.
    • Explain the indications & principles of surgery, chemotherapy, radiation, immunotherapy, targeted therapy, & hormone therapy.
    • Develop & evaluate plans of care for patients receiving chemotherapy or radiation.
  • Psychosocial Integrity
    • Recognize coping mechanisms in patients/families throughout the lifespan.
    • Provide culturally sensitive care & support for family/caregiver systems.
    • Collaborate with the interdisciplinary team to respect patient preferences & values.

Cancer: Definition & Epidemiology

  • Cancer = a group of diseases characterized by uncontrolled & unregulated cell growth.
  • Often a disease of aging
    • Most cases diagnosed at >55 y, yet can occur at any age (including pediatrics).
  • U.S. statistics
    • \approx 1.7\text{ million} new invasive cases/yr (excludes basal & squamous cell skin cancers).
    • Leading cause of death in ages 40\text{–}79.
    • Incidence & mortality are declining → multifactorial (better screening, prevention, therapy, ↓ tobacco use, genomic-targeted drugs, etc.).

Cellular Biology Review

  • Hypertrophy: ↑ tissue size by enlarging each cell.
  • Hyperplasia: ↑ tissue size by increasing cell number.
  • Immune system distinguishes self vs. non-self → targets non-self antigens.
  • Key genes
    • Proto-oncogenes: normal genes regulating growth & differentiation.
    • Tumor-suppressor genes: inhibit cell division/repair DNA; “the brakes.”
    • Oncogenes: mutated/over-expressed proto-oncogenes → drive malignancy.
  • Genetic contribution: 5\text{–}10\% of cancers have clear hereditary predisposition; \approx 90\% linked to environmental/behavioral factors.

Carcinogenesis (Oncogenesis)

  • A multistep process; three well-recognized stages:
    1. Initiation
    • Irreversible DNA mutation → loss of normal regulation.
    • Carcinogens: chemicals (e.g., benzene, chemo agents), radiation (UV, ionizing), viruses (HPV, EBV, HBV, HCV, HIV, HTLV-1).
    1. Promotion
    • Reversible proliferation of the initiated cell under influence of promoting factors.
    • Examples: dietary fat, obesity, cigarette smoking, alcohol, chronic inflammation.
    • Latent period between initiation & clinical detection can span years.
    1. Progression
    • Increased growth rate, invasiveness, angiogenesis.
    • Tumor develops its own blood supply via VEGF, FGF, etc.
  • Metastasis
    • Cancer cells detach, invade lymph/blood, survive immune attack, arrest in new organ, proliferate → secondary tumors.
    • Common routes: lymphatic spread, hematogenous spread, seeding of body cavities.

Cellular Characteristics: Normal vs. Benign vs. Malignant

  • Morphology
    • Normal: specific appearance; benign: resembles parent tissue; malignant: anaplasia (loss of differentiation).
  • Nuclear-cytoplasmic ratio
    • Normal/benign: small nucleus; malignant: large, irregular nucleus.
  • Differentiated function
    • Normal: perform intended function (e.g., keratin, bile).
    • Benign: often still functional; malignant: loss of function.
  • Adherence
    • Normal/benign: tight junctions via surface proteins.
    • Malignant: loose adherence → easy detachment & spread.
  • Migration
    • Normal/benign: non-migratory.
    • Malignant: capable of migration/metastasis.
  • Growth control
    • Normal: orderly, contact inhibition, finite cell cycles, apoptosis.
    • Benign: hyperplastic expansion but controlled.
    • Malignant: rapid/continuous division, no contact inhibition, immortal (evade apoptosis).
  • Chromosomal pattern
    • Normal/benign: 23 pairs (euploidy).
    • Malignant: aneuploidy—loss, gain, or broken chromosomes correlating with aggressiveness.

Nomenclature of Tumors

  • Primary (parent) site = tissue of origin.
  • Secondary (metastatic) site = spread via lymph/blood/serosal seeding.
  • Carcinogenesis/Oncogenesis both denote cancer development.

Classification & Staging

  1. Histologic Grading
    • Grade I: mild dysplasia, well-differentiated (low grade).
    • Grade II: moderate dysplasia, moderately differentiated.
    • Grade III: severe dysplasia, poorly differentiated (high grade).
    • Grade IV: anaplastic, undifferentiated; cell of origin difficult to ID (highest grade).
    • Grade X: cannot be assessed.
  2. Clinical Staging (extent of disease)
    • Stage 0: in situ (preinvasive).
    • Stage I: confined to tissue of origin.
    • Stage II: limited local spread.
    • Stage III: extensive local/regional spread.
    • Stage IV: distant metastasis.
  3. TNM System (site-specific)
    • T = primary tumor size/extent (T0\text{–}T4).
    • N = regional lymph node involvement (N0\text{–}N3).
    • M = distant metastasis (M0\text{–}M1).

Etiology, Risk Factors & Prevention

  • "CAUTION" 7 warning signs (Table 15-6)
    • C: Change in bowel/bladder habits
    • A: A sore that doesn’t heal
    • U: Unusual bleeding/discharge
    • T: Thickening/lump
    • I: Indigestion/dysphagia
    • O: Obvious change in wart/mole
    • N: Nagging cough/hoarseness
  • Environmental/lifestyle factors (≈90\%)
    • Tobacco, UV radiation, occupational exposures, viral agents, alcohol, diet (low-fiber; high animal fat; nitrites/preservatives), obesity, sedentary lifestyle.
  • Personal factors
    • Immune competence, age-related immune decline, genetic polymorphisms.
  • Primary Prevention (avoid initiation)
    • Avoid known carcinogens: smoking cessation, sun/UV protection, occupational PPE.
    • Modify risk: diet ↔ high fiber/plant-based, healthy BMI, physical activity.
    • Prophylactic surgery: removal of premalignant lesions, mastectomy/oophorectomy for BRCA-positive patients.
    • Vaccination: HPV (Gardasil, Cervarix) → prevents cervical, anal, oropharyngeal cancers; HBV vaccine → ↓ hepatocellular carcinoma.
  • Secondary Prevention (detect early)
    • Regular evidence-based screenings
    • Colonoscopy age 50 q10 yrs; FOBT yearly.
    • Mammography starting age 40 (annual) or per newest guidelines.
    • Pap/HPV per guidelines (21-65 y).
    • DRE & PSA in men \ge 50 (shared decision-making).
    • Genetic testing: BRCA1/2 (breast/ovarian), APC, MLH1, MSH2 (colon), RET (thyroid) etc.—provides risk, NOT diagnosis; require counseling.

Diagnostic Evaluation

  • Depends on suspected site; multimodal.
    • Cytology: Pap smear, bronchial washings.
    • Tissue biopsy = removal of tissue sample for histologic analysis (gold standard).
    • Percutaneous (needle through skin), endoscopic, fine-needle aspiration, large-core, excisional (entire lesion), incisional (partial sample).
    • Imaging: chest X-ray, CT, MRI, US, mammography.
    • Molecular imaging: PET, SPECT, radioisotope scans.
    • Laboratory
    • CBC, CMP, LFTs.
    • Tumor markers: CA\;19\text{–}9 (pancreas), CEA (colon), AFP (liver), PSA (prostate), β\text{-hCG} (germ cell).
    • Genetic markers.
    • Bone marrow aspiration/biopsy for hematologic cancers.

Treatment Goals

  1. Cure – complete eradication of disease; highest chance of long-term survival.
  2. Control – containment of cancer when cure not possible but disease is responsive.
  3. Palliation – relief/control of symptoms, maintenance of quality of life.

Therapeutic Modalities

Surgical Therapy (oldest form)

  • Prevention (prophylactic), cure/control (resection of tumor with adequate margins), debulking/cytoreductive (↓ tumor load prior to chemo/radiation), supportive/palliative (e.g., feeding tube, colostomy, pain relief).

Chemotherapy (antineoplastic drugs)

  • Systemic therapy → reaches primary & metastatic sites.
  • Drug classes
    • Alkylating agents (cyclophosphamide).
    • Antimetabolites (5-FU, methotrexate).
    • Antitumor antibiotics (doxorubicin).
    • Mitotic inhibitors (vincristine, paclitaxel).
    • Topoisomerase inhibitors (etoposide, irinotecan).
  • Nadir: lowest blood counts post-treatment (usually 7\text{–}14 days); critical for infection/bleeding precautions.
  • Dosage/route
    • Mostly IV; dosing based on \text{BSA (m}^2) & organ function.
  • Extravasation (vesicants)
    • S/S: pain, erythema, blistering, necrosis.
    • Most important nursing intervention = prevention (use CVAD, verify patency, frequent assessment; immediately stop infusion if suspected).
  • PPE for staff: eye shield, mask, chemo-rated double gloves, gown, shoe covers; safe handling of excreta 48\text{–}72 h.

Radiation Therapy

  • Mechanism: ionizing radiation damages DNA → cell death.
  • Dosing terms
    • Exposure: amount delivered.
    • Absorbed dose: \text{Gray (Gy)} – energy absorbed per unit mass.
  • Delivery
    • Teletherapy (external beam): patient not radioactive.
    • Brachytherapy (internal, sealed or unsealed sources)
    • Examples: radioactive iodine-131 for thyroid; hepatic Y-90 microspheres; intracavitary Cs-137 for cervical cancer.
  • Nursing considerations for brachytherapy
    • Principle ALARA: As Low As Reasonably Achievable → minimize time, maximize distance, use shielding.
    • Wear film badge/dosimeter; lead apron; cluster care; no pregnant staff/visitors; limit visitation <30 \text{min}/day, \ge 6 \text{ft} away.
  • Acute skin reactions: follow evidence-based skin care (no lotion/alcohol on site unless prescribed; lukewarm water; protect from sun; avoid tight clothing). Do not remove positioning tattoos.
  • Manage fatigue, nutrition (small frequent meals, supplements), xerostomia, exercise.

Immunotherapy / Biological Response Modifiers

  • Enhance host antitumor response or directly target cells.
    • Cytokines: interferons, interleukins, colony-stimulating factors.
    • Checkpoint inhibitors: \text{PD-1, PD-L1, CTLA-4} antibodies.
  • Monoclonal Antibodies (mAbs)
    • Bind specific antigens → block growth signals, deliver toxins/radioisotopes, trigger immune lysis (e.g., rituximab, trastuzumab).
  • Key side effects: infusion reactions, autoimmune phenomena, flu-like symptoms.

Targeted Therapy

  • Small-molecule inhibitors (e.g., tyrosine kinase inhibitors, angiogenesis inhibitors) → interfere with molecular targets critical for tumor growth.

Hormonal Therapy

  • For hormone-sensitive tumors (breast, prostate, endometrial)
    • Block hormone receptors (tamoxifen), aromatase inhibitors, LHRH agonists, anti-androgens.
  • Possible effects
    • Women: virilization (facial hair), acne, hypercalcemia.
    • Men: gynecomastia, testicular atrophy.
    • Steroid-like (fluid retention, weight gain), ↑ VTE risk with estrogens/progestins.
    • Monitor liver function.
  • Surgical ablation: oophorectomy, orchiectomy to ↓ hormone source.

Hematopoietic Stem Cell Transplant (HSCT)

  • Allows myeloablative chemo/total body irradiation followed by rescue infusion of stem cells.
  • Types
    1. Allogeneic (HLA-matched donor).
    2. Syngeneic (identical twin).
    3. Autologous (patient’s own previously harvested cells).
  • Nursing alerts
    • Patient will experience profound myelosuppression/immunosuppression post-conditioning → strict protective isolation, prophylactic antibiotics, antifungals, antivirals.
    • Monitor for graft-versus-host disease (allogeneic): skin rash, liver dysfunction, GI symptoms.

Nursing Management of Treatment-Related Side Effects (Table 15-11)

  • Bone Marrow Suppression
    • Neutropenia (ANC < 1000/\mu L) → infection risk; implement neutropenic precautions, filgrastim 5\;\mu g/kg SQ, monitor temp >38℃.
    • Thrombocytopenia (<100,000/\mu L) → bleeding precautions, platelet transfusions.
    • Anemia → fatigue; administer epoetin-α or transfuse PRBCs.
  • Nausea & Vomiting
    • Pre-medicate with 5-HT3 antagonists (ondansetron), NK1 inhibitors, corticosteroids; small bland meals.
  • Stomatitis/Mucositis/Esophagitis
    • Oral hygiene q4 h, saline/baking soda rinses, topical anesthetics (viscous lidocaine), soft diet.
  • Alopecia
    • Discuss temporary nature, wig/scarf options, scalp cooling caps.
  • Cognitive Changes ("chemo-brain")
    • Memory aids, schedule optimization, reassurance.
  • Chemotherapy-Induced Peripheral Neuropathy
    • Dose adjustments, gabapentin, safety measures for fall prevention.
  • Fatigue
    • Exercise programs, energy conservation, sleep hygiene.

Psychosocial & Cultural Considerations

  • Assess coping style, spiritual beliefs, family dynamics.
  • Provide anticipatory guidance; refer to social work, chaplaincy, support groups.
  • Use culturally congruent communication; accommodate language, dietary, spiritual needs.
  • Respect autonomy & treatment preferences; engage in shared decision-making.
  • Support caregivers: education, respite resources, mental health screening.

Interdisciplinary Collaboration

  • Oncology nurses, physicians (med-onc, rad-onc, surg-onc), pharmacists, dietitians, PT/OT, social workers, psychologists, palliative care, case managers.
  • Goal: holistic, patient-centered care across the continuum (diagnosis → survivorship or end-of-life).

Ethical, Legal & Practical Implications

  • Informed consent (diagnostics, treatment, clinical trials).
  • Genetic privacy & potential discrimination (GINA law in U.S.).
  • Balance of beneficence vs. non-maleficence when determining aggressive therapy vs. quality of life.
  • Advance directives, POLST, palliative vs. curative intent.
  • Cost of care, resource allocation, access disparities.

Quick Reference Numbers & Formulas

  • 1.7 \times 10^{6} = estimated annual new invasive cancers in U.S.
  • Genetic predisposition: 5\text{–}10\%; environmental factors: 90\%.
  • Human chromosomes: 23 pairs (euploidy).
  • Neutropenia critical value: ANC = \frac{(%\text{Neutrophils} + %\text{Bands}) \times WBC}{100}; risk <1000/\mu L.
  • Radiation dose often expressed in \text{Gray (Gy)} where 1\;\text{Gy} = 1\;\text{J}/\text{kg}.
  • Chemotherapy dosing by Body Surface Area: BSA\; (m^2) = \sqrt{ \frac{height(cm) \times weight(kg)}{3600} }.

Lifespan & Special Populations

  • Pediatric: tailor doses, developmental support, fertility preservation (sperm/ovum banking).
  • Older adults: comorbidities, polypharmacy, altered pharmacokinetics, geriatric assessment.
  • Pregnancy: timing of chemo (generally avoid 1st trimester), radiation shielding, ethical counseling.

Key Take-Home Points for Exam Preparation

  • Memorize the three stages of carcinogenesis & examples of promoters.
  • Differentiate benign vs. malignant cell characteristics.
  • Know grading vs. staging vs. TNM.
  • Recall "CAUTION" warning signs & primary/secondary prevention strategies.
  • Understand nadir timing & neutropenic precautions.
  • Be able to teach skin care during radiation & PPE during brachytherapy (ALARA).
  • Recognize major chemotherapy classes & hallmark toxicities.
  • Identify treatment goals (cure, control, palliation) & align nursing interventions accordingly.
  • Apply psychosocial principles: coping, cultural competence, caregiver support.
  • Grasp stem cell transplant principles, graft-versus-host, & protective isolation measures.