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.