ONCOLOGY
HOW DOES CANCER
HAPPEN?
•Stem cells (and all body cells) should always have normal identical
daughter cells. Stem cells should differentiate (mature) normally
•Initiation: the first mutation (can be inherited, from carcinogen, genetic
predisposition, virus) starts changing the cell.
–Once this happens… NO going back.
•Promotion: promoting agent—like carcinogens, high-fat diet, other
chemicals/environmental factors)
–Minimizing promotion factors lengthens this phase (latent phase is after
mutation before clinical presentation—depends on cell division rate and
environment)
–Also depends on how mutated the cell is…
–Critical mass: about 1 cm (1-1.5 billion cells) is when cancer mass is
physically palpable. Can be seen on MRI at 0.5 cm already
HOW DOES CANCER
HAPPEN?
•Progression: proliferation, local invasion metastasis
–Primary tumor “seeds” to new site, usually from
blood/lymph or physical manipulation
–Most common sites of metastasis: BBLLA = Brain Bone
Lung Liver Adrenals (these sites are very vascular and
connected to lymphatic system)
HOW DO CANCER
CELLS SURVIVE?
•Immunological escape: mutated cells not detected by immune system
–Antigenic tolerance: immune system doesn’t trigger response
–Overwhelming antigen exposure: too many cancer cells immune system
decides they must be normal
–Suppression of T cells
•Oncofetal antigens: during early development, cells have oncofetal
antigens to protect from the immature immune system attacking them
–Normally, these go away after the immune system matures. But cancer
cells use them to evade the immune system
–These are specific markers that indicate the presence of a tumor!
Diagnostic markers like PSA (prostate-specific antigen), CEA (colon cancer
marker)
CANCER STAGING:
HISTOLOGIC TUMOR GRADING
•Differentiation = maturity!
•Dysplasia = how different look from normal
•Grade I: well differentiated, only look slightly different than
normal cells
•Grade II: moderately differentiated, moderate dysplasia
•Grade III: poorly differentiated, severe dysplasia, very abnormal
•Grade IV: undifferentiated, anaplasia (NO resemblance to
normal), primitive cells
–These are hard to find even the cell of origin! And hardest to treat.
•Grade X: cannot be assessed
CANCER STAGING:
CLINICAL
•Stage O: cancer in situ, self-contained/encapsulated
•Stage I: cancer localized to tissue of origin
•Stage II: limited local spread
•Stage III: extensive local/regional spread
•Stage IV: metastasis
CANCER STAGING:
TNM
•T (primary tumor)
–T0: no evidence of primary tumor
–Tis: carcinoma in situ
–T1-4: bigger tumors/involvement
•N (lymph involvement)
–N0: no nodes involved
–N1-4: more nodes involved farther from primary site
–Nx: can’t assess nodes
•M (metastasis)
–M0: no evidence of mets
–M1-4: more mets farther from primary site
CANCER WARNING
SIGNS
•CAUTION
•Change in bowel/bladder function
•A sore the doesn’t heal
•Unusual bleeding/discharge
•Thickening of lump in breast
•Indigestion/difficulty swallowing
•Obvious change in wart/nevi
•Nagging cough/hoarseness
CANCER TREATMENT
•Goals: cure, control, palliation (comfort)
•Surgery
•Chemotherapy
•Radiation
•Biological/targeted therapy (directly work against
specific cancer cells, often use with chemo)
SURGERY
•Lots of reasons—from prophylactic mastectomies,
diagnostic biopsies, inserting devices for supportive
care, rehab, palliation, and cure/control of cancer itself.
•Grieving, loss of self-image, body alteration
•Potential for recurrence
•Did they “get it all?” What other treatments will they
need?
CHEMOTHERAPY
•Systemic chemical treatment—KILLS cells
•How well it works depends on how fast the cancer cells are dividing, how
big/old/where is the tumor, is tumor resistant?
•Used for solid tumors or hematologic cancer
•Lots of different ways it can given—most common is central vascular access
•If you give IV, chemo is EXTREMELY vesicant—which means if it gets out of the
vein (infiltrates/extravasates), it will KILL tissue. STOP THE INFUSION if any sign
of problem. And if no problems, still change IV site at least every 72 hrs
•Side effects (chemo kills fast-growing cells—like hair follicles, GI tract, skin,
bone marrow)
–So alopecia (hair loss), immunosuppression
–N/V significant problem—always give antiemetics before
–Fatigue, nutritional concerns
RADIATION
•Local treatment for solid tumors: focused on specific area
•Low-energy beams: short-distance, good for skin lesions
•High-energy beams: penetrate deeper, can target internal area
without hurting skin as much
•***SKIN CARE very important
–No alcohol-based/perfumed lotions OR soaps. Only very gentle
stuff (Ivory/Dove)
–Keep clean and covered, avoid sun
–Watch for damage
–Don’t wash off markings (these are so they know next time where
to target the radiation)
CHEMO + RADIATION
COMBO
•Even more bone marrow suppression, fatigue, GI
problems (nausea from radiation too),
integumental/mucosal problems, location-specific
effects depending on where radiation is
HOLISTIC CANCER
CARE
•Emotions, anticipatory and final grief
•End-of-life concerns
•Financial concerns
•Survival guilt/anger, counseling
•Life role reassignments
LEUKEMIAS
•Leukemia = cancer of leukocytes (WBCs)
•Acute: rapid-onset, immature cells (so more mature cells
don’t show up in the blood)
•Chronic: slow, insidious onset, mature cells
•Myelogenous: origin is myelocytes
•Lymphocytic: origin is lymphocytes
•Common symptoms: low RBC, Hgb, Hct, platelets. So
anemia, bleeding, fatigue, etc
•WBC count can vary…
ACUTE
MYELOGENOUS
LEUKEMIA (AML)
•Most common in older adults (60-70)
•Classic leukemia symptoms but sudden dramatic
onset w/ infection & bleeding
•Lots of immature myoblasts (precursors to granulocyte
WBCs) – so lymphadenopathy
ACUTE LYMPHOCYTIC
LEUKEMIA (ALL)
•*Most common childhood leukemia
•Classic symptoms + fever, weight loss, abdominal pain,
hepato-splenomegaly
•Leukemic meningitis: can invade/infiltrate arachnoid
mater and cause CNS effects
•Immature lymphoblasts
CHRONIC
MYELOGENOUS
LEUKEMIA (CML)
•Most common in middle age
•Asymptomatic early on, gradual development of fatigue,
sternal/joint/bone pain, incr sweating
•With time, massive splenomegaly
•**This is an exception—high platelets early on, then drop
•Don’t really treat actual cancer for a while—just anemia. Cancer
treatment can be more harmful than the actual cancer, at least for
many years they can be fine.
•BUT blast crisis: suddenly changes to AML, mature cells become
immature, can be life-threatening
–*educate your pts so they though they need to get rapid treatment if they
suddenly start feeling very bad!!
CHRONIC
LYMPHOCYTIC
LEUKEMIA (CLL)
•Most common in men (middle/older age)
•Mostly asymptomatic… but chronic fatigue/anorexia,
splenomegaly, maybe pain from swollen lymph nodes
•Incr risk of infection
•Mild anemia/thrombocytopenia, more lymphocytes in
blood and bone marrow, worsens w/ disease
progression
HAIRY CELL
LEUKEMIA
•Pretty rare, affects B lymphocytes, cancer cells look
“hairy”
•Chronic
•Most common men >40
•Splenomegaly, pancytopenia, incr risk of infection
UNCLASSIFIED
LEUKEMIA
•Mixed presentation so both mature & immature cells
•Usually very rapid-onset
•*POOR response. Hard to target specific cells since
variety. THE hardest to treat, may need multiple
chemos
LEUKEMIA
TREATMENT
•CHEMOTHERAPY is #1
•Stem cell/bone marrow transplants: basically rid pt of almost all body cells so
donor cells can replace—risky b/c severe pancytopenia before.
•Can also use radiation
•Since ALL can invade meninges, cranial radiation, intrathecal (in the brain)
methotrexate
•CML: total body radiation, alpha interferon, leukapheresis (filter cancerous
WBCs out of blood)
•CLL: total body/lymph/spleen radiation, splenectomy, alpha interferon, colony
stimulating factors (stimulate cell formation to counter pancytopenia)
•Once in remission for 8 years, you can basically be considered CURED.
Basically not coming back after that.
HODGKIN’S
LYMPHOMA
•Lymphomas are cancers of lymphocytes, starting in
bone marrow!
•Reed-Sternberg cells (b/c Hodgkin’s has just one
specific type of cell, pretty easy to target chemo and
treat effectively)
•Doesn’t spread outside lymphatic system
•Most common young men (15-35)
•Associated with Epstein Barr Virus (and genes/chemical
toxins like all cancers…)
NON-HODGKIN’S
LYMPHOMA (NHL)
•Most common hematologic cancer… Unfortunately. Also
5th leading cause of death from cancer
•Heterogenous (variety of cancer cells, no Reed-
Sternberg cells), so harder to treat
•Can also spread outside lymphatic system (very
common). Do biopsies/MRIs to try to find pattern of
spread
•Not as good prognosis
•Chemo, if it doesn’t work stem cell transplant
LYMPH NODE
BIOPSIES
•Can be open (surgical) or closed (needle aspiration)
•Pressure to avoid bleeding
•Watch for infection
•**The biopsy ONLY tells you about the specific site/node
it came from. So take multiple biopsies form multiple
nodes to see how it’s spreading
MULTIPLE MYELOMA
•Plasma cancer that invades & destroys BONE, large
multinucleated cells
•More common in older men
•Generally only symptomatic when advanced—bone PAIN and
destruction
•Hypercalcemia b/c of bone demineralization—this can cause
renal, GI (anorexia), and neuro problems (confusion)
•Can also see granulocytopenia, thrombocytopenia, anemia
•Dx: blood, urine tests, x-rays, bone marrow biopsies
•VERY poor response to chemo :(
MULTIPLE MYELOMA
CARE
•B/c hypercalcemia—always watch I&Os, urine output
should be at least 1.5-2 L/day. This is to decr Ca
concentration through renal system to save your
kidneys (too much Ca can clog them).
•B/c bone demineralization: fracture precautions
(osteoporosis)
•B/c pain: Aredia is great for skeletal pain, can also use
opiates, NSAIDs
•Also need to do LOTS of ROM. It hurts, but otherwise,
they will get contractures! And their bone will break if
you try to release the contracture!
•Tx w/ chemo/radiation
QUESTIONS
A characteristic of the stage of progression in the
development of cancer is:
•Oncogenic viral transformation of target cells
•A reversible steady growth facilitated by carcinogens
•A period of latency before clinical detection of cancer
•Proliferation of cancer cells despite host control
mechanisms
A characteristic of the stage of progression in the
development of cancer is:
•Oncogenic viral transformation of target cells
•A reversible steady growth facilitated by carcinogens
•A period of latency before clinical detection of cancer
•Proliferation of cancer cells despite host
control mechanisms
You are an RN evaluating the following patients. Who
do you most suspect to have cancer?
•Pt complaining of headache
•Pt with a cough for the past 2 days
•Pt complaining of a sore that they have had for 3
weeks
•Pt with dysrhythmia
You are an RN evaluating the following patients. Who
do you most suspect to have cancer?
•Pt complaining of headache
•Pt with a cough for the past 2 days
•Pt complaining of a sore that they have had for
3 weeks
•Pt with dysrhythmia
You are the RN caring for a patient who has just had a
double mastectomy. Which is an appropriate statement?
•“I know this must be hard for you, but at least we got
all the cancer out!”
•“I know this is a challenging time, but it will get better.”
•“Have you considered reconstruction options?”
•“I know you just had a large surgery, how have you
been handling this?”
You are the RN caring for a patient who has just had a
double mastectomy. Which is an appropriate statement?
•“I know this must be hard for you, but at least we got
all the cancer out!”
•“I know this is a challenging time, but it will get better.”
•“Have you considered reconstruction options?”
•“I know you just had a large surgery, how have
you been handling this?”
The goals of cancer treatment are based on the principle
that:
•Surgery is the single most effective treatment for cancer
•Initial treatment is always directed toward cure of the
cancer
•A combination of treatment modalities is effective for
controlling many cancers
•Although cancer cure is rare, quality of life can be increased
with treatment modalities
The goals of cancer treatment are based on the principle
that:
•Surgery is the single most effective treatment for cancer
•Initial treatment is always directed toward cure of the
cancer
•A combination of treatment modalities is effective
for controlling many cancers
•Although cancer cure is rare, quality of life can be increased
with treatment modalities
You find that your patient’s IV that is running a chemo
drug has infiltrated. What is your first action as an RN?
•Remove the IV
•Stop the infusion
•Call the doctor
•Apply a warm washcloth to the area to relieve pain
You find that your patient’s IV that is
running a chemo drug has infiltrated.
What is your first action as an RN?
•Remove the IV
•Stop the infusion
•Call the doctor
•Apply a warm washcloth to the
area to relieve pain
You are discharging a patient who received chemotherapy
and radiation yesterday. Which statement the patient
makes concerns you the most?
•“I will go for a gentle 5 mile walk tomorrow morning
when I feel up to it.”
•“I plan to go home and play checkers with my wife the
rest of the day.”
•“I am very tired- I think I will sleep when I get home.”
You are discharging a patient who received chemotherapy
and radiation yesterday. Which statement the patient
makes concerns you the most?
•“I will go for a gentle 5 mile walk tomorrow
morning when I feel up to it.”
•“I plan to go home and play checkers with my wife the
rest of the day.”
•“I am very tired- I think I will sleep when I get home.”
While caring for a patient receiving radiation treatment,
which of the following are not correct? (SATA)
•Use a good soap to remove markings so that the patient
does not get ink poisoning
•Get as much sun exposure as possible in order to obtain
enough vitamin D
•Keep the skin moisturized with Bath and Body Works lotion
•Use a saline solution to cleanse the area
While caring for a patient receiving radiation treatment,
which of the following are not correct? (SATA)
•Use a good soap to remove markings so that the
patient does not get ink poisoning
•Get as much sun exposure as possible in order to
obtain enough vitamin D
•Keep the skin moisturized with Bath and Body Works
lotion
•Use a saline solution to cleanse the area
A pt on chemotherapy and radiation has a WBC count of
1,900, hemoglobin of 10.8, and a platelet count of 9,900.
Based on these labs, what is the most serious clinical
finding?
•Cough, rhinitis, and sore throat
•Fatigue, nausea, and skin redness at site of radiation
•Temperature of 101.9 degrees F, fatigue, and SOB
•Skin redness at site of radiation, headache, and
constipation
A patient on chemotherapy and radiation has a WBC
count of 1,900, hemoglobin of 10.8, and a platelet count
of 9,900. Based on these labs, what is the most serious
clinical finding?
•Cough, rhinitis, and sore throat
•Fatigue, nausea, and skin redness at site of radiation
•Temperature of 101.9 degrees F, fatigue, and SOB
•Skin redness at site of radiation, headache, and
constipation
•Jim makes an appointment with his PCP because he has
been having increasing amounts of joint pain over the
past year & recently he began to develop tenderness on
his left side. The lab work is back & Jim’s H&H is decr.
but his platelets are incr. What type of leukemia does
Jim most likely have?
–ALL
–CML
–AML
–CLL
•Jim makes an appointment with his PCP because he has
been having increasing amounts of joint pain over the
past year & recently he began to develop tenderness on
his left side. The lab work is back & Jim’s H&H is decr.
but his platelets are incr. What type of leukemia does
Jim most likely have?
–ALL
–CML
–AML
–CLL
•Bonnie, a 65yr. old female, presented to the E.D. with a
rapid onset of flu-like symptoms & bleeding mouth
sores. Her labs revealed a hemoglobin of 8mg/dL & a
hematocrit of 15%.
–CML
–ALL
–CLL
–AML
•Bonnie, a 65yr. old female, presented to the E.D. with a
rapid onset of flu-like symptoms & bleeding mouth
sores. Her labs revealed a hemoglobin of 8mg/dL & a
hematocrit of 15%.
–CML
–ALL
–CLL
–AML
•A 5yr. old presents to the E.R. with a fever of unknown
etiology, weight loss, and a low CBC. Upon X-ray he has
transverse lines at the end of the metaphysis of his
femur bones. What kind of leukemia is the child
suffering from
–Wilm’s Tumor
–ALL
–CML
–AML
•A 5yr. old presents to the E.R. with a fever of unknown
etiology, weight loss, and a low CBC. Upon X-ray he has
transverse lines at the end of the metaphysis of his
femur bones. What kind of leukemia is the child
suffering from
–Wilm’s Tumor
–ALL
–CML
–AML
•The 5yr. old child was diagnosed w/ ALL. What is an
unusual characteristic about ALL metastasis and how is
it treated?
–ALL can metastasize to the pinky finger requiring an
amputation
–ALL can metastasize to the spleen requiring a
splenectomy
–ALL can metastasize to the liver requiring a liver resection
–ALL can metastasize to the brain and spinal cord requiring
cranial radiation & intrathecal chemo
•The 5yr. old child was diagnosed w/ ALL. What is an
unusual characteristic about ALL metastasis and how is
it treated?
–ALL can metastasize to the pinky finger requiring an
amputation
–ALL can metastasize to the spleen requiring a
splenectomy
–ALL can metastasize to the liver requiring a liver resection
–ALL can metastasize to the brain and spinal cord
requiring cranial radiation & intrathecal chemo
•James (60yrs.) complains of pain around his jaw, at the
back of his head, and under his arms. The patient also
has been extremely tired recently and lost his appetite.
What is the most likely type of leukemia that he is
suffering from?
–ALL
–CML
–CLL
–AML
•James (60yrs.) complains of pain around his jaw, at the
back of his head, and under his arms. The patient also
has been extremely tired recently and lost his appetite.
What is the most likely type of leukemia that he is
suffering from?
–ALL
–CML
–CLL
–AML
•Things associated w/ Hodgkins Lymphoma include:
(SATA)
–Most common hematologic cancer
–Poor prognosis
–Reed Sternberg Cells
–Epstein Bar Virus
–Heterogenous Malignant Cells
–Incr. risk if exposed to chemical toxins
•Things associated w/ Hodgkins Lymphoma include:
(SATA)
–Most common hematologic cancer
–Poor prognosis
–Reed Sternberg Cells
–Epstein Bar Virus
–Heterogenous Malignant Cells
–Incr. risk if exposed to chemical toxins
•Billy is diagnosed with Non-Hodgkins Lymphoma and
when he comes for his check-up he informs his provider
that his best friend told him that Non-Hodgkins is the
better type to have because it doesn’t metastasize to
extranodal sites. True or False?
•Billy is diagnosed with Non-Hodgkins Lymphoma and
when he comes for his check-up he informs his provider
that his best friend told him that Non-Hodgkins is the
better type to have because it doesn’t metastasize to
extranodal sites. True or False?
–FALSE
•A patient presents to the E.D. with a leg fracture after
having stepped off his front porch. He is complaining of
pain, which is attributed to his fracture, but after
receiving labs it is discovered that his Ca+ is
11.0mg/dL. An x-ray is performed an multiple lesions
are discovered on his femur bone. What is the pt.’s
likely diagnosis?
–Hyperparathyroidism
–Drinks too much milk
–Normal findings post fracture
–Multiple Myeloma
•A patient presents to the E.D. with a leg fracture after
having stepped off his front porch. He is complaining of
pain, which is attributed to his fracture, but after
receiving labs it is discovered that his Ca+ is
11.0mg/dL. An x-ray is performed an multiple lesions
are discovered on his femur bone. What is the pt.’s
likely diagnosis?
–Hyperparathyroidism
–Drinks too much milk
–Normal findings post fracture
–Multiple Myeloma
•The patient receives a lymph node biopsy on one of his
axillary lymph nodes for supposed Non-Hodgkins
Lymphoma. The test result is negative for cancer, is it
safe to tell the patient that he is cancer free? Yes or No
& Why?
•No! They only tested one lymph node! Who knows if
any of the other hundreds of lymph nodes have cancer.
