NCLEX-RN: Oncology Nursing

Oncology Nursing: Detection and Prevention of Cancer

Focus topic: Oncology Nursing

Oncology Nursing: Cancer Incidence and Trends

Focus topic: Oncology Nursing

A. Cancer—a definition.

  • Term represents a group of more than 200 neoplastic diseases that involve all body organs.
  • One or more cells lose their normal growth controlling mechanism and continue to grow uncontrolled. They tend to invade surrounding tissue and to metastasize to distant body sites.

B. Second leading cause of death in United States after heart disease.

  • Ranks fourth for males and first for females as cause of death; second after accidents as cause of death for children.
  • Greatest increase seen in lung cancer—consistent with smoking patterns.

C. Incidence rate.

  • 1.2 million in United States are diagnosed with cancer every year. It is predicted that the incidence of cancer in the United States could double by the middle of the century, due to growth and aging of population.
  • Number of cancer deaths increased by 11% during past 40 years.
  • Leading causes of cancer death are lungs, prostate, and colorectal for males; lungs, breast, and colorectal for females.
  • Most common site of cancer for a female is the cervix.

D. Steps in controlling cancer:

  • Educate the public and professional people about cancer.
  • Encourage methods of primary prevention.

Oncology Nursing: Identified Causes and Risk Factors

Focus topic: Oncology Nursing

A. Multiplicity theory: Multiple factors lead to the development of cancer; 60–90% thought to be related to environmental factors.
B. Carcinogens: agents known to increase susceptibility to cancer.

  • Chemical carcinogens: asbestos, benzene, vinyl chloride, by-products of tobacco, arsenic, cadmium, nickel, radiation, and mustard gas.
  • Iatrogenic chemical agents: diethylstilbestrol (DES); chemotherapy; hormone treatment; immunosuppressive agents, radioisotopes, cytotoxic drugs.
  • Radiation carcinogens: x-rays; sunlight (ultraviolet light); nuclear radiation.
  •  Viral factors: herpes simplex; Epstein–Barr; hepatitis B, and retroviruses.
  • Genetic factors: hereditary or familial tendencies.
  • Demographic and geographic factors.
  • Dietary factors: obesity; high-fat diet; diets low in fiber; diets high in smoked or salted foods; preservatives and food additives; alcohol.
  • Psychological factors: stress.
  • Age.

Oncology Nursing: Primary Prevention Measures

Focus topic: Oncology Nursing

A. Optimal dietary patterns and lifestyle changes.*

  • Dietary factors are related to 50% of all environmental cancers.
  • Avoid obesity (at 40% overweight, there is a 55% increased risk of cancer in females and 33% increased risk in males).
  • Decrease fat intake of both saturated and unsaturated fats—maximum 30% of total calories.
  • Increase total fiber in diet—decreases risk of colon cancer.
  • Increase cruciferous vegetables (cabbage, broccoli, carrots, Brussels sprouts).
  • Increase vitamin A—reduced incidence of larynx, esophagus, and lung cancers.
  • Increase vitamin C—aids tumor encapsulation and promotes longer survival time.
  • Increase vitamin E—inhibits growth of brain tumors, melanomas, and leukemias.
  • Decrease alcohol consumption.
  • Avoid salt—cured, smoked, or nitrate-cured foods.

B. Minimize exposure to carcinogens.

  • Avoid smoking—thought to be a cause of 75% of lung cancers in United States.
  • Avoid oral tobacco—increases incidence of oral cancers.
  • Avoid exposure to asbestos fibers and constant environmental dust.
  • Avoid exposure to chemicals.
  • Avoid radiation exposure and excessive exposure to sunlight.

C. Obtain adequate rest and exercise to decrease stress.

  • Chronic stress associated with decreased immune system functioning.
  • Strong immune system responsible for destruction of developing malignant cells.
  • Participate in a regular exercise program.
  • Get adequate rest (6–8 hours per night).
  • Have a physical exam on a regular basis, including recommended diagnostic tests.
Oncology Nursing

Oncology Nursing: Secondary Prevention—Early Detection

Focus topic: Oncology Nursing

A. Risk assessment (see Identified Causes and Risk Factors, p. 470).
B. Health history and physical assessment.
C. Screening methods.

  • Mammography, Pap test, prostate exam, prostate- specific antigen (PSA) blood test, etc. Self-care practices: breast self-examination (BSE) done every month on a regular time schedule; testicular self-examination (TSE) done every month; skin inspection.
  • Colonoscopy for males and females 50 years and older.
  • Fecal occult blood test for males and females 40 years and older.

Characteristics
A. Benign neoplasms: usually encapsulated, remain localized, and are slow growing.
B. Malignant neoplasms: not encapsulated, will metastasize and grow, and exert negative effects on host.
C. Categories of malignant neoplasms.

  • Carcinomas—grown from epithelial cells; usually solid tumors (skin, stomach, colon, breast, rectal).
  • Sarcomas—arise from muscle, bone, fat, or connective tissue—may be solid.
  • Lymphomas—arise from lymphoid tissue (infection-fighting organs).
  • Leukemias and myelomas—grow from bloodforming organs.

D. Mechanisms of metastases.

  • Transport of cancer cells occurs through the lymph system and either the cells reside in lymph nodes or pass between venous and lymphatic circulation.
    a. Tumors that begin in areas of the body that have extensive lymph circulation are at high risk for metastasis (breast tissue).
    b. The speed of metastasis is directly related to the vascularity of the tumor.
    c. Angiogenesis: Cancer cells induce growth of new capillaries; thus cells can spread through this network.
    d. Hematogenous: Cancer cells are disseminated through the bloodstream. The bloodstream may carry cells from one site to another (liver to bone).
  • Direct spread of cancer cells (seeding) where there are no boundaries to stop the growth (e.g., ovary and stomach).
  • Transplantation is the transfer of cells from one site to another.

Oncology Nursing: COMPARISON OF CHARACTERISTICS OF BENIGN AND MALIGNANT TUMORS

Focus topic: Oncology Nursing

Oncology Nursing

Diagnosis
A. Diagnostic studies will depend on suspected primary site and symptoms.
B. Laboratory and radiologic tests often identify a problem first.

  • Radiographic procedures (e.g., tomography, computed tomography [CT], contrast studies).
  • Ultrasonography.
  • Radioisotopic scanning studies (e.g., brain scan, gallium imaging).
  • Magnetic resonance imaging (MRI).
  • Biologic response markers (useful for diagnosing primary tumors, a parameter used to measure the progress of disease or the effects of treatment).
  • Positron emission tomography (PET).
    Radioactive glucose is injected prior to scanning. Areas of high glucose uptake, such as rapidly dividing cancer cells, are dramatically displayed in the scam images.
    a. PET scans reveal cellular-level metabolic changes occurring in an organ or tissue. This is important and unique because disease processes often begin with functional changes at cellular level.
    b. PET scan can measure such vital functions as blood flow, oxygen use, and glucose metabolism, which helps doctors identify abnormal from normal-functioning organs and tissues.
    c. Scan can also be used to evaluate the effectiveness of a treatment plan, allowing client’s course of care to be adjusted if necessary.

C. Other laboratory tests.

  • Enzyme tests, such as acid phosphatase.
  • Tumor marker: ID analysis of substances found in blood or body fluids.

Oncology Nursing: Cancer Classification

Focus topic: Oncology Nursing

Grading
A. Grading refers to classifying tumor cells—done by biopsy, cytology, or surgical excision.

  • Tumor grade is one of many factors that doctors consider when they develop a treatment plan for a cancer client. It is not the same as staging.
  • Tumor grade refers to the degree of abnormality of cancer cells compared with normal cells under a microscope.
  • Tumor grade is an indicator of how quickly the tumor is likely to grow and spread.
  • Tumor grading systems differ depending on the type of cancer.
  • Tumor grade may be one of the factors considered when planning treatment for a client.

B. Biopsy: definitive diagnosis of cancer.

  • Excisional biopsy—removes all suspicious tissue. Used for small tumors < 2 cm.
  • Incisional biopsy—removes a sample of tissue from a mass.
  • Needle aspiration—aspiration of small amount of core tissue from a suspicious area.
  • Exfoliative cytology—scraping of any endothelium cells in tissue or secretions is applied to a slide and evaluated (e.g., cervix— Pap smear of mucous membranes).

C. Tissue specimens are evaluated by frozen or permanent sections by a pathologist.
D. Results from biopsy and other diagnostic procedures (blood tests, x-ray studies, endoscopic procedures) will determine extent of disease staging.

Oncology Nursing: GRADING TUMORS

Focus topic: Oncology Nursing

Oncology Nursing

Staging
A. Staging describes the size of the tumor and extent or metastasis of a malignant tumor; also quantifies severity of disease.
B. A useful system of staging for carcinomas is the TNM system.

  • T: Primary tumor.
  • N: Regional nodes.
  • M: Metastasis.
    For many cancers, TNM combinations correspond to one of five stages. Criteria for stages differ for different types of cancer. For example, bladder cancer T3 N0 M0 is stage III, whereas colon cancer T3 N0 M0 is stage II.

C. The extent to which malignancy has increased in size

  • Primary tumor (T).
    a. TX: tumor cannot be assessed.
    b. T0: no evidence of primary tumor.
    c. TIS: carcinoma in situ.
    d. T1, T2, T3, T4: progressive increase in tumor size and involvement.
  • Involvement of regional nodes (N).
    a. NX: regional lymph nodes cannot be assessed clinically.
    b. N0: regional lymph nodes not abnormal.
    c. N1, N2, N3, N4: increasing degree of abnormal regional lymph nodes.
  • Metastatic development (M).
    a. MX: not assessed.
    b. M0: no evidence of distant metastasis.
    c. M1 to M4: increasing degree of distant metastasis.

D. Another method of staging: Many cancer registries, such as those supported by the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology, and End Results (SEER) Program, use “summary staging.” This system is used for all types of cancer. It groups cancer cases into five main categories:

  • In situ: Abnormal cells are present only in the layer of cells in which they developed.
  • Localized: Cancer is limited to the organ in which it began, without evidence of spread.
  • Regional: Cancer has spread beyond the primary site to nearby lymph nodes or tissues and organs.
  • Distant: Cancer has spread from the primary site to distant tissues or organs or to distant lymph nodes.
  • Unknown: There is not enough information to determine the stage.

Oncology Nursing: CLINICAL STAG ING OF TUMORS

Focus topic: Oncology Nursing

Oncology Nursing

Oncology Nursing: Treatment Methods

Focus topic: Oncology Nursing

A. Broad goals.

  • Goal of therapy is to cure the client—eradicate the tumor.
  • When cure is not possible, controlling or arresting the tumor growth becomes the goal—to prolong survival.
  • Palliation or alleviation of symptoms.

B. The gold standard for cancer treatment remains surgery, radiation therapy, chemotherapy, and combined approaches.

C. The newest weapon against cancer is adoptive immunotherapy (AIT).

  • AIT uses principles of vaccine therapy.
    a. Cells from tumor tissue are cloned, treated in a lab, and injected back into the client for increased immune response.
    b. Days after the vaccine is administered, lymph nodes are harvested so the T cells can replicate; these are then infused into the client.
    c. Method is currently in clinical trials; side effects minimal (as opposed to radiation and chemotherapy).
  • With AIT, the biologic response modifier is the reactive T-cell solution; activated T cells in the body fight the tumor.

Oncology Nursing: Surgery

Focus topic: Oncology Nursing

A. Useful as primary treatment for localized cancer (breast, colon, melanoma of skin, etc.).

  • Highest rate of cure for localized disease.
  • Disadvantage—deforming or debilitating to client.

B. Types of treatment.

  • Local excision: simple surgery with small margin of normal tissue surrounding tumor—used when tumor is small.
  • En bloc dissection or wide excision; removal of tumor, nodes, tissues, and any contiguous structures.
  • Video-assisted endoscopic surgery is replacing surgery with long incisions; surgery is done through two or three short incisions via a camera to remove tumor.
  • Surgery on cancer in situ.
    a. Electrosurgery—application of electrical current to destroy cancerous cells.
    b. Cryosurgery—deep freezing with liquid nitrogen to cause cell destruction.
    c. Chemosurgery—applied chemotherapeutic agents layer by layer with surgical excision.
    d. CO2 laser—use of laser for local excision.

C. Other forms of surgery.

  • Prophylactic: removal of tissue or organs that may develop cancer.
  • Cosmetic surgery: follows radical surgery.
    a. May be performed immediately following surgery, postsurgery, or in stages.
    b. Method is appropriate for breast, head, neck, and skin cancers.

D. Palliative surgery—promotes comfort and quality of life without cure.

Implementation
A. Preoperative care.

  • Promote health status prior to surgery.
    a. Malnourished client is at risk for infection, delayed wound healing, and dehiscence.
    b. Mental status may impact surgery results.
    c. Neomycin is often given before bowel surgery to suppresses normal bacterial flora, thereby “sterilizing” the bowel preoperatively to decrease the possibility of postoperative infection. However, it cannot prevent infection.
  • Provide emotional support prior to surgery.
    a. Encourage talking about fears and anxieties.
    b. Provide accurate information—clarify levels of knowledge.
    c. Assess family needs and provide information and support.

B. Postoperative care.

  • Provide traditional postop care.
  • Provide for physical comfort.
    a. Enteral feeding.
    b. Pain relief.
    c. Positioning (to maximize comfort and promote lung expansion).
    d. Activity.
    e. Wound care and healing.
  • Provide emotional support.
    a. Allow for grief process—encourage expression of fears.
    b. Discuss change in body image—support increase in self-esteem.
    c. Provide accurate information.
  • Support rehabilitation process.
    a. Encourage family involvement.
    b. Make referrals to appropriate resources.
    c. Complete discharge planning.

FURTHER READING/STUDY:

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