1. Oncology Dead Man’s party
Biology of abnormal cells
Cancer grading and stages
Cancer statistics
Chemotherapeutic agents
Radiation treatments
Bone Marrow and Stem Cell transplants
Onco-gene therapy

2. Oncology Objectives
1. Identify the different phases of cancer cell replication.
2. Compare the features of a benign versus malignant tumor
3. Recognize the TNM stage and grading system of cancer tumors.
4. Discuss the role of oncogenes and suppressor genes in cancer development.
5. Identify behaviors with corresponding primary and secondary nursing prevention for risks of cancer development
6. Recognize the different classes of chemotherapies.
7. Create appropriate nursing interventions for a case study of a patient with cancer.

3. Oncology Objectives
8. Identify appropriate testing for cancer patients.
9. Recognize signs and symptoms of chemotherapy side effects.
10. Recognize signs and symptoms of radiation therapy.
11. Prioritize nursing interventions for a patient with neutropenia.
12. Prioritize nursing interventions for a patient with thrombocytopenia.
13. Prioritize nursing interventions for a patient receiving bone marrow or stem cell transplant.

4. Oncology Objectives
14. List 4 risk factors for the development of leukemia.
15.Compare Leukemia and Lymphoma pathophysiology, etiology and clinical manifestations.

5. Cellular Review
Evolve 3D Cellular Differentiation on web site

6. Oncology Biology of abnormal cancer cells
They have continuous or inappropriate, usually faster growth or larger growth patterns
They have no specific morphology and often do not resemble their parent cells = anaplastic
They do not respond to signals for apoptosis = programmed cell death

7. Oncology Biology of abnormal cancer cells
Have a large nuclear – cytoplasmic ratio; the nucleus may occupy most of the cell area
They lose some or all of their normal cell functions
They do not make fibronectin, and thus cannot connect easily and break off easily

8. Oncology Biology of abnormal cancer cells
They are able to migrate throughout the body = metastasis
They invade other tissues and types of cells.
They are not controlled by contact
They have more or less chromosomes than the parent cells = aneuploid
or a mutation of the genes

9. Oncology Cancer development
Initiation – there are many theories as to when the genes in the cells are damaged, maybe in utero, from physical or chemical exposure, latent oncogenes, viruses, or a lack of suppressor genes from our parents, and at this point the cell is not dividing.

10. Oncology
Skin cells

11. Oncology Cancer development
Promotion - the stage when the abnormal cell starts to divide, may be stimulated by environmental changes, hormones, drugs, or irritants

12. Oncology Cancer development
Progression – the phase when the abnormal cells have continued to grow into a Primary tumor, may produce angiogenesis factors which supply blood and vascular nourishment to the tumor. The tumor may have subcolonies of cells with different genes and features

13. Oncology Cancer development Metastasis
the movement of cancer cells into other organs of the body, thus creating new tumor sites.

14. Oncology Cancer grading and staging
Cancer is graded upon the resemblance to normal cells = G
(The higher the number, the worse the grade of cancer) i.e. G1, G2, G3, G4
Staging is based upon
the presence of a primary tumor = T
involvement in lymph nodes = N
and appearance of metastasis = M
Numbers of the stage range from
x = none to 3 or 4 for each letter

15. Oncology Is this a high grade or low grade cancer? Case study
Julie has a breast lump in her right breast, and has also found one in her right armpit. Biopsy and lumpectomy were performed. The tumor was graded G3, T2, N2, M1.

16. Is this a high grade or low grade cancer?

17. Oncology
Julie opted to have a lymphectomy of her right arm lymph nodes, and started radiation treatment right away. Her doctor also suggested that she start Adriamycin IV chemotherapy to get any cells that the radiation might miss.

18. Oncology Cancer Risks #1 = advancing age #2 = smoking tobacco
Hormones – Prempro caused a substantial increase in breast cancer on the HERS trial
Genetic inheritance of oncogenes and autoimmune diseases
Environmental exposure
Excessive intake of dietary fats

19. Oncology Cancer risks High alcohol consumption
Low dietary vegetables and fiber (sources of antioxidants)
Previous Viral infections:
Hepatitis B or C
Herpes viruses
Papilloma viruses (HPV)
Retrovirus HTLV –I

20. Oncology Types of cancer cells are named for their site of origin:
Adenocarcinoma
Carcinoma in situ (CIS)
Squamous
Basal cell
Astrocytomas
Melanomas
Sarcomas
Lymphomas

21. Oncology Symptoms of Cancer Cachexia – weight loss,unexplained
Anorexia
Anemia
Impaired immune response
Pain – when the cancer is large enough to compress nerves or organs
Lymphadema – when the tumor blocks lymph or circulatory flow
Motor or sensory deficits

22. Oncology
The 60 year old client with small cell lung cancer is concerned that his grown children also might develop the disease. What is the nurses best response?
A. “This disease is a random event and there is no way to prevent it.”
B. “Because this disease is inherited as a dominant trait, your children have a 50% risk for developing it.”
C. “Cigarette smoking is the main cause of this disease, and helping your children not to smoke will decrease their risk.”
D. “ Lung cancer can be avoided by decreasing dietary intake of fats and increasing the amount of regular aerobic exercise.”

23. Oncology Cancer statistics
The top four cancers found in the United States are:
Lung
Breast
Prostate
Colorectal C

24. Oncology Cancer statistics
Prostate cancer is the most common site of cancer and the 2nd most common cause of cancer death in the United States
The first cause of death in males is Lung Cancer

25. Oncology

26. Oncology Cancer statistics Lung cancer has annual
new cases (incidence)
of 173,770 people
per year: 93,110 males and
80,660 females
Annual mortality: 160,440 per year consisting of 92,000 males and
68,510 females

27. Oncology Cancer statistics
28% of all cancer deaths are due to lung cancer
This is the leading cause of cancer death in both men and women
There are more deaths from lung cancer than prostate, breast, and colorectal cancers combined

28. Oncology Cancer statistics Risks for lung cancer:
Smoking (75-80% of cases)
Occupational exposure
Nutrition/Diet
Genetic factors

29. Oncology Cancer statistics
Prostate cancer is number two cause of cancer in men
Breast Cancer is number two cause of cancer in women
Most common non-malignant or non-fatal cancer is non-melanoma type skin cancers

30. Oncology
The client says that she has heard that the origin of most cancers is “genetic”. What is the nurse’s best response?
A. “The development of most cancers is predetermined and not affected by environmental factors.”
B. “Cancers arise in cells that have been damaged,which may be in the genes”.
C. “ The majority of cancers are inherited”
D. “Cancer is more common among males than females.”

31. Oncology Lab tests for cancer Ultrasounds to determine size
CT scan with contrast– the golden standard
Genetic markers – BRCA 1 and BRCA 2
Tumor markers:
CEA – general carcinogenic antigen
PSA – prostate antigen
CA-125 – ovarian
CA-25,27 – breast
HER 2 NEU – breast tissue needed

32. Oncology Lab tests for cancer Liver function tests CBC with diff
Renal function tests
PET scan – looks for metastasis using a radioactive glucose solution
PT, PTT, Fibrinogen, Fibrin levels

33. Oncology Lab tests for cancer Pathology slide of tumor:
(Should be kept for a period of years)
Determines type of tumor
Source of tumor
Aggression of tumor – whether fast growing, differentiated, or non-differentiated
Used to determine tumor growth factors and susceptibility to certain chemotherapies

34. Oncology Chemotherapy
Prevention chemotherapy – for high risk patients, precancerous lesions, or history of cancer
Antioxidants, vitamins
Aldara cream 3x weekly for precancerous skin lesions
Aspirin
Protease inhibitors

35. Oncology
Chemotherapy - typically started after surgical dissection of tumor, unless the tumor is non-operative
Usually given by a long term venous access device, i.e. PICC line, implanted ports, or direct catheratization to the tumor.
Chemotherapy is usually potent and horribly scarring on normal veins

37. Oncology Chemotherapy
Biochemotherapy – used as in-patient or outpatient settings for cancer, MS, and viral treatments:
Alpha interferon – (IFN)- Alpha 2a,
Roferon, Intron-A-
used for leukemias, AIDS, Hep-C
Beta interferon – Beta 1b
– used for renal carcinoma, melanoma, AIDS, MS, Hepatitis A, B

38. Oncology Chemotherapy/Biochemotherapy Interleukin I (IL-1)
Interleukin 2 (IL-2), Proleukin– stimulates growth of T-cells and NK cytotoxic cells
– used investigationally for melanoma in Stage II to Stage IV cases on a monthly basis with a 80% non-recurrence rate

39. Oncology Chemotherapy/Biochemotherapy
Tumor necrosis factor (TNF) – selectively targets abnormal cells, in nature is produced by NK cells

40. Oncology Chemotherapy/Biochemotherapy Vaccines
HPV vaccine for cervical cancer
Melanoma vaccine - for stage II only at this time, or malignant melanoma

41. Oncology
Chemotherapy/Biochemotherapy Monoclonal antibodies – used for treatment of cancer, rheumatoid arthritis, transplants, and other autoimmune diseases. Can be used to stimulate immune response or suppress it.
Rituximab – Treatment of CD20 –positive non-Hodgkins B-cell lymphoma
Gentuzumab – treatment of CD33 positive AML in first relapse in patients who are not candidates for reg. chemo.

42. Oncology Adalimumab – Humira
Chemotherapy/Biochemotherapy Monoclonal antibodies
Adalimumab – Humira
–new treatment for severe rheumatoid arthritis, given s.q every other week
Alemtuzumab – Campath
- treatment of B-cell lymphoma who have failed traditional chemotherapy with fludarabine
Basilixamab – Simulect
- immunosuppressive monoclonal antibody for renal transplants

43. Oncology Chemotherapy – Alkylating agents Bisulfan oral
Carboplatin (CBDCA) IV
Chlorambucil (leukeran) oral
Cisplatin IV
Cyclophosphamide(Cytoxan) IV or PO
Melphalan (Alkeran) oral
Ifosfamide IV
Thiotepa IV or PO

44. Oncology Chemotherapy/ Antibiotics given IV as chemotherapy
Adriamycin (Doxirubicin)
Bleomycin
Dactinomycin
Daunorubicin (actinomycin D)
Idarubicin (idomycin)
Mitomycin C
Mithramycin

45. Oncology Chemotherapy – anti-metabolites Cytorubine (Cytosar) IV
Floxuridine (FUDR) IA or SQ
Flourourcil (5FU) IV
Fludara IV
Hydroxyurea PO or IV
Methotrexate IV or IM
6MP PO
IRESSA PO
Xeloda PO

46. Oncology Chemotherapy- Hormones Progestins – uterine cancer Estrogens
Testosterone - myelodysplasias
Anti-hormones – block hormonal activity in hormone sensitive cancers:
Leupron
Eulexin
Tamoxifen/Nolvadex
Arimedex/Arista

47. Oncology Chemotherapy – Plant alkaloids Vinblastine (Velban) IV
Vincristine (Oncovin) IV
Vindesine IV
Eldisine IV
The first doses of this are usually given in a hospital setting, are vesicants, and neurotoxic. Nurses must wear protective gear!

48. Special biohazard bags for disposal
Which of the following are appropriate protective gear for the nurse when hanging chemotherapy?
Splash goggles
Latex gloves
Rubber gloves
Paper gown
Special biohazard bags for disposal
Lead apron

49. Oncology Chemotherapy –Antimitotics Dacarbazine (DTIC – Dome) IV
Leukovorin PO or IV
Paclitaxol (Taxol) IV
Topotecan IV
Gemzar IV
Docetaxol IV
Camptothecan (CPT-11) IV
Taxotere (Ormaplatin) IV

50. Oncology Side effects of Chemotherapy Alopecia Fatigue Anemia
Leukopenia
Thrombocytopenia
Always – Nausea,Vomiting, Diarrhea
Neurotoxicity & neuropathies
Capillary leakage
Headaches
Fluid and electrolyte imbalances

51. Oncology Side effects of Chemotherapy Anorexia – change in taste buds
Back aches
Joint aches
Blood clots
Oral mucositis – (reduced significantly by L-glutamine amino acids orally)
Supra opportunistic infections
Septic DIC
Tumor lysis syndrome
Edema or pulmonary edema

52. Oncology Chemotherapy Nursing Interventions
Evaluate and assess sites of chronic chemotherapy, ports, veins, skin area
Accurate I & O’s
Monitor for fluid overload or dehydration
Monitor lab electrolytes before and after infusion
Monitor BUN and Creatinine
Monitor CBC with differential during the time of Nadir
Monitor PT, PTT

53. Oncology Cancer Nursing Interventions
Nutritional assessment and weights
Dentition – oral checks
Monitor for signs of suprainfection, low grade temperatures, rash, etc…
Vital signs before, during, and after treatments
Assess bowel status
Assess pain level

54. Oncology Cancer Nursing Interventions
Educate patients and family members:
side effects of treatments, meds
care of port and IV sites
oral hygiene
symptoms to report, i.e. shortness of breath or signs of infection
Increase fluid intake, suck on hard candies to reduce chemotherapy metallic tastes

55. Oncology Nursing Diagnoses Disturbance in self esteem, body image
Altered nutrition, less than body requirements
Risk for fluid volume excess or deficit
Impaired skin integrity
Pain, chronic
Decreased cardiac output
Self-care deficit
Sexual dysfunction

56. Oncology Nursing Diagnoses Alteration in tissue perfusion
Knowledge deficit
Risk for injury
Impaired physical mobility
Sensory perception alterations
Alterations in bowel patterns
Alterations in mucous membranes
Anxiety and Fear

57. Oncology Nursing Diagnoses Depression Grief Respiratory compromise
Ineffective coping
Spiritual distress
Impaired social interactions
Sleep pattern disturbance
Altered family roles

58. Oncology Pharmacological interventions
Megace, Marinol – for appetite stimulation
Premedications for nausea, vomiting, edema, headaches: usually on the protocol for chemo
Antiemetics;
Zofran – 24 hour control
Tigan, Kytril, ativan, anzamet, Compazine, benadryl, reglan
Corticosteroids

59. Oncology Pharmacological interventions Analgesics
IV electrolytes and fluid replacement
Stool softeners to counteract constipation from opioids
GSF for WBC’s
Epogen/Procrit for anemia
Leukine/Prokine for leukopenia
Neupogen for neutrophilia
Neumega for thrombocytopenia
Diuretics for edema

60. Oncology Non-Pharmacological interventions Massage Reflexology
Accupuncture
Musical therapy
Prayer
Meditation
Diversional acitivities
Dietary counselling

61. Oncology Radiation therapy
All types of cells are injured or destroyed by concentrated radiation. Rapidly dividing cells are the most sensitive.

62. Oncology Radiation therapy Types : Gamma knife Local beam treatment
Local seeding
ARC – stereotactic
Radioimmunotherapy
Fractionation
Total body irradiation
Particle beam therapy, i.e. proton or neutron therapy

63. Oncology Radiation therapy side effects
Side effects depend on the amount and area being irradiated
Fatigue
Nausea and vomiting
Mild anemia
Leukopenia
Diarrhea
Pain

64. Oncology Radiation therapy side effects: Erythema/burns Fatigue
Pneumonitis
Esophagitis
Dysphasia
(Please educate your patients on
these as doctors are notoriously
bad at pre-educating their patients).

65. Debilitating fatigue Mucositis hair loss nausea and vomiting
What side effects of radiation therapy would you expect to see in a 48-year-old woman with breast cancer?
Debilitating fatigue
Mucositis
hair loss
nausea and vomiting

66. Burns Anemia Skin care Diet All of the above
What are some of the educational issues for patients receiving radiation treatment
Burns
Anemia
Skin care
Diet
All of the above

67. Oncology Nursing interventions for radiation TX
Assess incidence and severity of side effects
Maximize radiation protection, all wastes will be radioactive if isotopes are injected
Shielding for staff

68. Oncology Malignant Lymphomas – 2 types
Hodgkin's Lymphoma – most common cancer in 10 to 20 year olds (young adults). Associated with an inflammatory process related to +EBV/mono infection.
Diagnosis: Classic Reed-Steinberg cell with two mirrored nuclei, CT scan
Symptoms: Extreme fatigue, enlarged lymph nodes that are painless. May progress to weight loss fevers, night sweats

69. Oncology Malignant Lymphomas – 2 types Hodgkin's Lymphoma
Treatment – combined radiation and chemotherapy, stem cell transplants if resistant type or recurring
85% curable
(90% in some institutions)

70. Oncology Malignant Lymphomas – 2 types
Non-Hodgkins Lymphoma – 3 times more common than Hodgkin’s lymphoma, can either be T-cell lymphomas, or B-cell lymphomas
Can be low grade or high grade disease. B-cell lymphomas = 50% and usually are more aggressive tumors. Since they grow faster, they are also more sensitive to radiation and chemotherapy

71. Oncology Malignant Lymphomas – 2 types Non-Hodgkins Lymphoma
Diagnosis: bone marrow biopsy, CT scan, lymphoma panel with CD markers
Symptoms- adenopathy, spleenomegaly with vague abdominal pain, back pain, and since immunity B or T-cell function is affected- the patient is more prone to infections. Subcutaneous T-cell lymphoma is a classic discoid rash on the upper body and trunk that does not respond to steroids or creams.
NHL can progress rapidly to leukemia if untreated.

72. Oncology Malignant Lymphomas – 2 types Non-Hodgkins Lymphoma
Treatments: Monoclonal antibodies, chemotherapy with Fludara/Fludarabine, radiation therapy, and bone marrow implants

73. Oncology
Leukemia– hematopoeitic cancer of the stem cells. These stem cells proliferate into non-functional immature white cells.
More children get leukemia than any other type of cancer and it is the #1 cause of death in children.
Anyone can get leukemia at any age.

74. Oncology Leukemia -4 types Acute lymphoblastic leukemia (ALL)
Acute myelogenous leukemia (AML)
Chronic Lymphocytic leukemia (CLL)
Chronic myelogenous leukemia (CML)
Anagram – ALL AniMals are CLearLy
CaMeLs

75. Oncology
Leukemia –ALL suspected cause is a T-cell virus (HTLV-1) – 85% is seen in children, 25% in adults 30-to-40 y.o.
Diagnosis: peripheral blood smear after abnormally high white count, bone marrow biopsy shows lymphoblasts >50%m may have decrease in platelets. Lumbar puncture to determine CSF involvement

76. Oncology Leukemia –ALL
Symptoms – fatigue, anorexia, malaise, weight loss, bleeding, infections, headaches, adenopathy, spleenomegaly, gingival hypertrophy, hepatomegaly, bone or joint pain
Treatment: complete response is a bone marrow aspirate with < 5% blasts. Chemotherapy – vincristine, prednisone, danorubicin, methotrexate,
Maintenance therapy – 6 weeks of
6-mercaptopurine and methotrexate low dose therapy

77. Oncology
Leukemia – AML – more common in patient’s with chromosomal genetic disorders, exposure to benzene or radiation. Use of alkylating agents for breast, ovarian, or myeloma are associated with a later malignancy of this type.
Symptoms- are like ALL with the additions of anemia, thrombocytopenia, visual disturbances, epistaxis (nosebleeds), headache with vomiting, dysphagia, papilladema, menorrhagia (lots more bleeding problems)

78. Oncology Leukemia – AML
Diagnosis: peripheral blood smear shows Auer bodies (rods), platelets less than 20,000/mm3,
bone marrow biopsy
Prognosis – poor prognosis if patient has already received radiation or chemotherapy, or has a WBC >100,000

79. Oncology Leukemia – AML
Treatment: Cytaribine chemotherapy in combination therapy with Danorubicin or doxirubicin, works 65% of the time.
Bone marrow transplant or stem cell transplant.

80. Oncology Leukemia – CLL – staged 0-5
chronic diseases have more mature cells, majority of CLL is B-cell proliferation – 95%. Only 5% are T-cells, more common in people with autoimmune diseases, i.e. SJogren’s, SLE, hemolytic anemia
Symptoms: skin and respiratory infections, fatigue, thrombocytopenia, anemia, spleenomegaly

81. Oncology Leukemia – CLL
Diagnosis- peripheral blood smear, bone marrow biopsy
Treatments: Gleevac – drug of choice; chemotherapy in combinations, spleenectomy, radiation therapy to spleen, bone marrow transplant, stem cell transplants

82. Oncology Leukemia – CML (last is the CaMeL)
- More common after radiation exposure, benzene exposure, less common than the other types of leukemia, and occurs most often between y.o.
Diagnosis: hallmark is the presence of the Philadelphia Chromosome, Chromosome #22 is missing part of the long arm which is translocated to Chromosome #9. This is present in 95% of those patients with CML.
WBC >100,000 with proliferation of all types of mature and immature white cells.
Bone marrow biopsy

83. Oncology Leukemia – CML
Symptoms: same as other leukemias with chronic fever, sternal tenderness and dyspnea – usually due to severe anemias
Treatments: chemotherapy with Bisulfan and hydroxurea, other combination chemos,
Interferon alpha 2b to suppress the expression of the Philadelphia chromosome.
Bone marrow transplant or stem cells

84. Oncology Bone marrow and stem cell implants New treatments for:
Acute myelogenous leukemias (AML)
Acute lymphoblastic leukemias (ALL)
Myelodysplasia syndromes (MDS)
Chronic myelogenous leukemias that do not respond to chemotherapy (CML)
Blast crisis
Pediatric acute leukemias
Non-Hodgkins lymphoma
Large B-Cell lymphoma
Multiple myelomas

85. Bone marrow and stem cell implants

86. Oncology Bone marrow and stem cell implants
Procedure= multiple punctures
Marrow acquisition from donor or when patient is in remission, or stem cells from umbilical blood of a matching sibling or family member
Marrow is filtered to purge tumor cells, fat and bone particles, then place in a blood bag for cryopreservation.

87. Oncology Bone marrow and stem cell implants Preparing Recipient:
Marrow recipient is given high dose chemotherapy alone or in combination with radiation to suppress immune system, open spaces in the marrow, and kill remaining cancer cells.
Bone marrow is thawed and infused through a central venous catheter

88. Oncology Bone marrow and stem cell implants Preparing Recipient:
Stem cells are infused after thawing
Post-procedure:
Patient is supported through the period of aplasia, 10 to 30 days, while in reverse isolation and on graft immunosuppressants,
Observed for signs of Graft-versus-host disease and/or infection

89. Oncology The waves of the future: Stem Cell Research
Oncogene therapy – now that cancer cells are being genetically tagged, we can tell which growth factors are present, and which enzymes turn off the gene. Soon all gene markers will have a pill that matches the enzyme, i.e. IRESSA is a tyramine kinase inhibitor, and stops the tumors growth that use tyramine kinase

90. Oncology
Stem Cell Induction – there are new drugs out for stem cell induction to immunosuppress the patient, even in deadly cancers, i.e. Multiple Myeloma. Recently, the combination of lenalidomide(Revalamid), bortezomib (Velcade) and dexamethasone produced a
98% response rate in patients

91. Oncology The waves of the future: Cancer vaccines
Oncology is the science of cancer and treatment of all cancer patients. It is one of the most demanding and rewarding fields in medicine.
The future is open for a cure.

92. Oncology