• Defect in proliferation (uncontrolled growth) & differentiation (become specialized)
• Can be benign (no mets) or malignant (invasive)
• Multifactoral origin: genetic, environmental, viral or immunologic.
• Affect African Americans more.
• Non-Hodgkin's rising in incidence.
• Melanoma fastest rising in US (men)
• Lung, colorectal, oral and breast cancer decreased

• cancer causing agent 
• enters nucleus and alters DNA
• cells: reapair themselves, die or replicate with alterations

reversible- change in lifestyle can reduce risk of cancer.

Smoking, obesity, alcohol, etc. 

T-tumor size and invasiveness

N-size and regional spread to lymph nodes

M-metastasis to distant organ site

• chemicals as systemic therapy to reduce # of malignant cancer cells.
• Used for most solid tumors and hematologic cancers
• continuous or intermittent
• cell cycle phase: nonspecific or specific
• Harzardous to handle:May be absorbed through skin
• Administration:
• Intracavitary, intrathecal, oral, infusion, VAD
• Cannot distinguish between normal and cancer cells. Affects tissues with rapid growth first (hair, GI, bone marrow)
• Body response to chemo:
• fatigue
• anorexia
• taste alterations
• Acute toxicity (during and immediately after)
• nausea, vomiting, allergic reactions, extravasation (flare reaction to dye).
• Delayed effects:
• mucositis, alopecia, rashes, altered bowel function, neutropenia, parasthesia, red color to urine, tears or sweat 1st hr after treatment->several days
• Chronic toxicities: damage to organs
• Given in combination treatments
• Dosages calculated by body surface area

• Manage side effects.
• Give antiemetics before treatment.
• Differentiate btwn tolerable vs. toxic side effects.
• Report serious reactions.
• Maintain oral care routine.
• Pain management.
• Don't shave, soft tooth brushes (hemorrhage)
• Monitor weight, I/O (anorexia, pulmonary edema)
• Watch for edema, dysrhythmias, HTN with infusion

Localized treatment.

Normal tissues usually able to recover.

• Primary cause of death in cancer patients.
• Instruct to call if temp >100.5 F
• Neutropenia caused by disease or treatment.
• Good handwashing essential
• Rocephin vs Hospitalization
• Can have fresh fruits only if peeled, no fresh flowers, dirty water, stay away from sick people
• 1-2 weeks NADIR

• Malnutrition
• supplement when 5% weightloss noted
• monitor albumin/prealbumin
• double strength milk for protein
• Altered taste sensation
• physiology unknown (cancer stimulates bitter taste buds?)
• experiment w/spices & seasonings

• Obstruction of SVC by tumor or thrombosis caused by lung cancer, non-Hodgkins or met. breast cancer
• S/S: facial & periorbital edema, vein distention of the head, neck or chest, headache

• Tumor in epidural space of spinal cord. Caused by: breast, lung, GI, prostate, melanoma.
• S/S: intense, localized persistant back pain, motor weakness, sensory parasthesia, changes in bladder or bowel function
• Treatment: radiation, steroids, surgical decompression

• Shifting of fluid from vascular space to interstitial space.
• S/S: hypovolemia, hypotension, tachycardia, low central venous pressure, low urine output
• Treatment: fluids, pressors

• Abnormal production of ADH (lung cancer)
• S/S: weight gain w/o edema, weakness, seizures, coma, nausea & vomiting
• Treatment: correct fluid/lyte balance, fluid restriction, IV of 3% NaCl, monitor Na levels

• Occurs with bone mets or multiple myeloma
• S/S: apathy, depression, fatigue, muscle weakness, EKG changes
• Treatment aimed at primary disease

• Rapid release of cancer cells during initial treatment leads to acute renal failure
• S/S: increased uric acid, phosphate & potassium. Decreased calcium. Begins 24-48 hrs after chemo, may be fatal
• Treatment: hydration therapy to increase urine output and decrease uric acid

• fluid in pericardial sac, constriction by tumor or pericarditis from radiation.
• S/S: heaviness in chest, SOB, tachy, cough, dysphagia, hoarseness, increased RR, hiccups, N/V.
• Treatment: reduce fluid around heart, O2, hydration, pressors

• >50yrs
• Family or personal history of cancer
• Menarche <12yr or Menopause>55yrs
• First pregnancy >30 years or nulliparity
• Hormone Replacement Therapy (combined)

• Gene abnormality gives 40-80% risk of getting breast cancer

• Most breast cancers arise in ducts (connect lobules w/nipples). Very invasive.

10-15% arise in lobules (milk producing glands).

Develops into invasive if untreated. Will spread to lung, bone, liver, brain.

• Cell membrane receptor overexpressed in breast cancer. Helps to regulate cell growth

• Rare, persistent lesion of the nipple w/ or w/o a mass.  
• s/s: Itching, burning, bloody discharge with erosion and ulceration.
• Treatment: radical or simple mastectomy

• Most malignant, rare.
• Agressive & fast growing.
• Mets occur early and widely.
• May be mistaken for infection (cancer cells block lymph channels)
• S/S: red, warm skin w/ thickened appearance (orange peel). Hive-like. 

• Lump most often in upper, outer quadrant of breast.
• Lesion- immobile, hard, non tender.
• Mass: hard, irregularly shaped, poorly delineated. 
• Nipple discharge, bleeding, Peau d'orange (orange peel), infiltrated skin, dimpling.
• Mets usually go to lymph nodes

• H & P
• Mammography: baseline @ 35yrs, each year after 40yrs, every other year for 65yrs+
• US, Biopsy, MRI, CX-ray, CBC, PET scan, CT

• Well differentiated
• Better prognosis
• Responds to Hormone Therapy

• Poorly differentiated.
• Recur frequently
• Unresponsive to Hormone Therapy

• Estrogen, Progesterone & HER-2
• More aggressive
• Poor Prognosis

• Surgery-most common for resectable
• Radiation
• Chemo
• Hormone therapy
• biologic & targeted therapy

• Primary Tx: Prevent local recurrence after surgery. 5-6 wks, does not prevent mets.

• Adjuvant Tx: Prevent local & nodal recurrences

• Palliative: pain, local recurrence or mets (bone, soft tissue organs, brain, chest)

• internal radiation with multicatheter implant
• Takes 5 days

• Tamoxifen- removes or blocks the source of estrogen if cells are estrogen receptor positive

• Herceptin- monoclonal antibody to HER-2.
• Attaches to antigen, enters cell and kills them.

• Only the tumor and some surrounding tissue is removed.
• Breast, muscle and lymph nodes are preserved as much as possible.

Removal of breast & axillary lymph nodes

Preserved pectoralis major

Best option for breast reconstruction

used when 1+ SLN are malignant.

Inject blue dye into lymph sytem: provides prognosis & treatment info. Usually involves removing 10-20 nodes

• Breast reconstruction to improve self-image and regain normalcy.
• Cannot restore nipple sensation or erectility, lactation, or erotic function.

• Monthly BSE, exam q 6months for 2 years, then yearly mammograms.
• Wear well-fitting prosthesis & bra 6 weeks post-op
• Call Dr. if: fever, inflammation at site, erythema, constipation, unusual swelling, new back pain, weakness, SOB.
• Pain control, coping with body image changes.

• Risk Factors: lifestyle, red meat consumption, age, family hx, polyps.
• More common in men, African Americans, >50years.
• 85% arise from adenomatous polyps
• Mets to liver & lungs most common

• nonspecific, insidious, late onset
• hematochezia-blood in rectum (left side)
• Melena-black tarry stools
• abdominal pain
• changes in bowel habits
• right sided: vague, colicky pain, anemia, weakness, fatigue

• Colonoscopy: gold standard, examine entire colon. Polyps removed & sent to lab
• Fecal occult blood tests (q yr >50yrs): doesn't detect non-bleeding tumors
• CBC, coagulation, liver function tests (mets)

• Surgery
• removal of tumor w/resection
• removal of lymph nodes in area
• Chemo & Radiation
• primary treatment for nonresectable cancer (w/lymph involvement)
• Avastin- prevents formation of new blood vessels (angiogenesis)
• May be adjuvant or palliative

• monitor bowel changes: rectal bleeding, diarrhea, constipation.
• Goals: normal bowel patterns, quality of life, pain relief.
• Post-op: clear liquid diet, dressings for drainage, ambulate ASAP
• Promotion: 50yr+
• Colonoscopy q 10 years
• Sigmoidoscopy, Double contrast enema & CT q 5 years
• Fecal occult blood test q year

• leading cause of cancer death. 
• leading cause of death in women 
• Risk factors: SMOKING, abestos, radon, pollution.
• Two types:
• Non-small cell: 80%
• Small cell: 20%
• 8-10 yrs for tumor to be 1 cm. Must be 1 cm to be detected by X-ray 

Early:

• asymptomatic, non-specific
• Pneumonitis- cough, fever & chills
• Persistent cough w/sputum
• Hemoptysis (blood in sputum)- most common
• Chest pain, dyspnea, wheezing

Later:

• anorexia, fatigue, N/V, hoarseness, palpable lymph nodes, weight loss.

• CX-ray (if >1cm)
• CT scan- most effective noninvasive technique
• MRI, PET, sputum cytology, biopsy, VAT

Surgery

• Used for Non-small cell only!!
• Pneumonectomy (entire lung) or lobectomy

Radiation

• Used for Non-small cell & small cell
• Curative approach & symptom relief 

Chemotherapy

• Small Cell: standard treatment
• Adjuvant for nonresectable and Non-small cell 

Biologic & Target Therapy

• drugs specifically block tumor growth
• Used when other treatments have failed

• Prophylactic Cranial radiation-for mets (chemo doesn't penetrate BBB) 

• Bronchoscopic Laser Therapy-removes obstructing bronchial lesions

• Photodynamic therapy-IV injection concentrates in tumor cells & then laser used

• Airway stenting-(palliation)- supports airway against collapse of external compression

• Airway, Oxygenation, Effective breathing, Pain mgmt., realistic attitude
• Support, nutrition, comfort
• Educate: s/s of hemoptysis, dysphagia, chest pain, hoarseness
• Promotion: avoid smoking, smoking cessation

• Malignant tumor of prostate. 
• Androgen dependent.
• Slow growing
• 1/5 men
• 2nd leading cause of cancer death in men
• 65+yrs 
• Increased in African Americans
• High fat diet
• BPH not a risk factor

• Asymptomatic early
• symptoms similar to BPH: dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption of urinary stream, inability to urinate.
• Pain in lumbar-sacral area->legs=mets
• Bone most common site for mets

• Prostate Specific Antigen (PSA)- glycoprotein increased (norm 0-4)
• Digital Rectal Exam (DRE)-finds hardness, nodular and asymmetric prostate
• Neither is definitive!! Biopsy needed to confirm
• Bone scan, CT, MRI, TRUS, PET- mets
• Prostatic Acid Phosphatase- elevated if mets

• Watchful waiting if: life expectancy <10yrs, significant comorbid disease, low-grade, low-stage tumor.

• Surgery: radical prostatectomy (entire gland, seminal vesicles, & part of bladder neck removed)
• most effective for long term survival
• Preferred treatment if <70yrs
• Retroperineal- incision btwn scrotum & anus (no lymph nodes)
• Retropubic- low, midline abdominal incision (lymph nodes dissected)
• Complications: incontinence, ED, hemorrhage, urinary retention, PE, DVT, infection
• Laproscopic, Nerve sparing procedure (try to prevent ED)
• Cryotherapy

• Radiation Therapy
• External beam radiation
• Used in <70yrs, poor surgical candidates
• SE: dry, red, irritated, painful skin, diarrhea, cramping, bleeding, dysuria, frequency, urgency, ED, fatigue, bone marrow suppression

• Radioactive seed into prostate gland
• Spares surrounding tissue
• SE: obstructive urinary problems, sterility

• reduce levels of androgens to reduce tumor growth b4 surgery or radiation
• tumors become resistant w/in a few years

• Surgical removal of testes (advanced stages)
• Testosterone stimulates growth of cancer.
• Pain relief- shrinks prostate=less urinary obstruction
• Reduces testosterone by 90%
• SE: hot flashes, ED, low libido, irritability, weight gain, loss of muscle mass, osteoporosis

• Poor response.
• Used with hormone resistant prostate cancer in late stages.
• Goal is palliation.

• Pain control, ED acceptance, manage bladder/bowel function.
• Catheter, cleaning, bag lower than bladder, fluid intake, s/s of infection.
• Encourage PSA & SRE starting at 50yrs 

• Pain
• Headaches w/vomiting (morning)
• Prolonged/unexplained Fever
• Paleness
• Anemia
• Abdominal or unusual mass
• Swollen lymph nodes
• Vision changes 
• Weight loss

• promote stem cell proliferation & maturation of cells
• Given 24 hrs after chemo for 7-10 days (ANC>10,000)
• SE: bone pain, fever, rash, malaise, headache
• ANC<500=potentional for infection
• Nursing: monitor temp closely, broad spectrum antibiotic, cultures to determine source of infection, Bactrim to prevent P.carinii, hand washing, peel fruit/veggies, no flowers, avoid crowds

• drop in platelets
• Use soft tooth brush, avoid rough activities. No: scissors, shaving, rectal temps, aspirin, etc.
• Check stool for blood

• from Cancer or drugs
• S/S: pale, tired, tachycardic
• Blood transfusion last resort

• give antiemetics before chemo
• Dronabinol: appetite stimulant
• Give chemo at bedtime with mild sedative

• High protein, high calorie foods, enteral feeding
• Food may taste bad: give them what they want

• Stomatitis
• bland, soft, moist diet. Soft toothbrush, mouth rinses (Na HCO3 sol), local anesthetic w/o alcohol
• Viscous lido- suppress gag reflux, increased risk for aspiration 

• warn pt & parents
• wigs, scarf, sunscreen use
• grows back in 3-6 months
• may be different color/texture

• warn parents.
• goes away after drug is stopped
• prevent with footboards

• develops 5-8 weeks after CNS irradiation
• Lasts 4-15 days
• S/S: severe drowsiness w/ or w/o fever, N/V

• short term->no toxicity & increases appetite
• SE: moon face, weight gain, mood swings
• Teach: avoid salt, goes away after drug stopped

• Malignant diseases of bone marrow and lymphatic system.
• Overproduction of immature WBCs
• ALL, AML, ANLL, stem or blast cell 
• Most common childhood cancer
• Onset 2-5 yrs

• Anemia
• Infection
• Bleeding tendencies
• Spleen, liver & lymph glands: infiltration, enlargement & fibrosis
• Bone pain from bone marrow destruction
• CNS & testes involvement

• Initially, minor infection but continues with:
• fever, pallor, listlessness, irritability, fatigue, anorexia, joint & bone pain. Late signs: bruising & weight loss

• Peripheral Blood smear: immature WBC, low BC
• Bone marrow aspiration or biopsy for confirmation
• LP-determine CNS involvement

• Chemotherapy
• Induction phase: 4-6 weeks, hit hard to induce remission.
• Intensification: further reduce # of cells 
• Maintenance: ensure remission
• CNS prophylaxis: intrathecal methotrexate
• Cranial irradiation 
• BMT after relapses

• Treat side effects: low WBC, N/V
• Prepare pt & family, provide support
• give blood for anemia, adequate rest.
• give platelets for hemorrhage, prevent bleeding

• Neoplastic diseases that arise from lymphoid & hematopoietic systems
• Hodgkin disease or Non-Hodgkin lymphoma

• Neoplastic disease, starts in lymphoid system
• Mostly in teens.
• often mets to: spleen, liver, bone marrow, lungs, other soft tissue.

• painless, firm, moveable enlargement of lymph nodes (supraclavicular & cervical)
• Persistent, non-productive cough
• Waldeyer's ring: hypertrophy of tonsils/adenoids
• Low grade, intermittent fever, night sweats, anorexia, weight loss, pruritus

• Lymph node biopsy
• Reed-Sternberg cells-only found in Hodgkins & mono

• Irradiation & Chemo
• common complication of radiation to the neck: hypothyroidism 

Hodgkin disease Nursing Considerations

• Malaise from irradiation, damage to thyroid
• May need splenectomy
• Prepare for secondary cancer, relapse, sterility from treatment. 
• Secondary sex characteristics my be altered/delayed
• Prepare, educate, support of pt & family

• Kids <14 yrs
• Diffuse rather than nodular, poorly differentiated cells.
• Early dissemination & invasion of meninges typical

• Depends on system involved
• Caused by mets & tumors pressing on organs/systems
• Burkitt: in Africa->mass in jaw, abdomen or orbit

• Agressive combo of chemotherapy & irradiation
• Prognosis 75-90% (extensive involvement), nearly 100% (limited involvement)

• 60% intratentorial- posterior 1/3 of brain (cerebellum & brainstem)
• 40% supratentorial- anterior 2/3 of brain (cerebrum)

• s/s related to anatomic location, size, and age
• Infants: asymptomatic (sutures/fontanelles opening), eventual listless, irritable, full fontanelles, increasing head circumference
• Kids: headache w/N&V upon waking (IICP stimulates vomiting centers), ataxia, personality changes, seizures, vision changes

• MRI- gold standard
• Angiography- determine blood supply & vascularity
• LP-dangerous w/IICP (possible brainstem herniation w/pressure release)
• Biopsy for definitive diagnosis

• Surgery: total removal is treatment of choice
• Radiotherapy: main treatment if non-operable, shrink before surgery. Delayed as long as possible (>3yrs)
• Chemotherapy: shrink before surgery
• Brain mapping & Lasers- vaporize tumor
• Steriods for edema

• Prepare pt & family (honesty, hair shaved, limitation after surgery)
• Obtain baselines, monitor for infection, pupil changes (report sluggish/dilated pupils immediately), amount of drainage from dressing
• Positioning: on opposite side, HOB elevated (prevent IICP & aspiration), Trendelenberg is contraindicated
• Fluids: NPO first 24 hrs (gag reflex), run @ 1/2 maintenance, foley, mannitol for IICP
• Comfort: analgesias for headache: dim room, visitor restriction, quiet music, no jarring movements, prevention of straining (stool softeners). Careful w/ sedation, analgesics, and narcotics
• Temp: potential for hyperthermia
• Respiratory: infection, meningitis, vomit->aspiration.
• Support parents, home restrictions (helmet, activity restrictions s/s of IICP & infection)

• most common malignant extracranial solid tumor of childhood
• Primary site is abdomen
• Silent Tumor: 1st sign usually caused by mets
• Poor prognosis
• Survival inverse relationship w/age: <1yr=75% survival, >1yr=50% survival

• Firm, nontender irregular mass midline
• Distant mets: supraorbital ecchymois, periorbital edema
• Lymphadenopthy: cervical & supraclavicular
• Vague symptoms: weakness, pallor, irritable, wt. loss

• CT, X-ray, PET.
• If in adrenal glands of sympathetic chain: excrete catecholamines in urine

• Has spontaneous regression
• Surgery to remove tumor
• Chemo: mainstay for extensive local and disseminated disease
• Radiation, Bone marrow transplant

• Osteosarcoma & Ewing sarcoma- 90% of bone tumors in kids
• Common in males, peak is 15 yrs 
• S/S: localized pain relieved by flexed position, palpable mass, fever. 
• Rule out trauma or infection first
• Definitive diagnosis: CT, PET, biopsy
• MRI, labs: elevated alkaline phosphatase

• Most frequent, peak 10-25 yrs.
• Occurs in metaphysis of long bones (distal femur, humerus, tibia, pelvis, jaw)
• "Sunburst appearance"
• Traditional treatment: radical surgical resection or amputation.
• New treatment: resection of bone with prosthetic replacement of affected area w/Chemo
• Optimal treatment: amputation & chemo
• Phantom limb pain-tingling, itching pain in amputated limb. Elavil used for pain.

• Arises in marrow
• "Onion skin" appearance
• long bones & trunk: femur, tibia, ulna, humerus, vertebrae, pelvis, scapula, ribs, skull
• Radiation first, Chemo as adjunct.
• Surgical resection possible
• Survival 80%

Rhabdomyosarcoma

• Malignant neoplasm starting from undifferentiated cells in muscle, tendon, bursa and fascia or fibrous, connective, lymphatic or vascular tissue
• Striated muscle especially in head and neck: orbit, nasopharynx, paranasal sinuses, middle ear, petroperitoneal area, perineum
• usually kids <5 yrs

• s/s depend on site and compression of adjacent tissue, vague and common (earache)
• Orbit: symptomatic early=diagnosis and good prognosis
• Retroperitoneal: late symptoms & poorer prognosis

• Highly malignant & mets often->aggressive treatment
• Surgical removal, Radiation, Chemo (1-2 yrs)

Wilm's Tumor

(nephroblastoma)

• Intraabdominal & renal malignant tumor.
• Peak 3-4 yrs

• S/S:Swelling/Mass in one side of the abdomen, deep in flank (usually left). Hematuria, anemia, HTN, wt. loss, fever

• Treatment: Surgical removal (usually encapsulated) and chemo (possible radiation 

• Nursing Considerations: rapid recovery, never palpate abdomen!!, monitor: BOS, BMs, distention, vomiting, BP

• Congenital malignant tumor of the retina
• Onset: 2 yrs
• S/S: Cat's eye reflex (leukocaria): white glow of the eye as light hits the tumor, strabismus, red, painful eye w/glaucoma, blindness (late)
• May regress spontaneously
• Treatment: plaque brachytherapy, irradiation, cryotherapy, enucleation (advanced)
• Nursing Considerations: care of prosthetic (3 wks after OR), eye patches, ointment.

• Not common, generally malignant
• Ages 15-44yrs
• S/S: heavy, painless, testicular swelling
• Treatment: orchiectomy & node removal then chemo or radiation
• Nursing Considerations: TSEs

• Chemo may cause secondary cancers later
• Development affected by drugs and disease
• Decreased fertility, sterility
• Osteoporosis & cardiomyopathies