MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 1

CANCER BIOLOGY
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 22 2021
TRANSCRIBED BY TOM CUENCA, ROGEN AZARCON, CHRISTINE SUNGA & CAMILLE BUTAO

OVERVIEW • Mitosis (M) phase: Culminates in the division of the parent cell into
• Cancer is a generic term for a large group of diseases that can affect two exact copies called the daughter cells.
any body part of the body. Other terms used are malignant tumors • After that, the cell will enter G1 phase and start another cell cycle or
and neoplasms. divert into a resting phase called your G0 phase.
• One defining feature of cancer is the rapid creation of abnormal cells • It is important to take note that something can go wrong with the cell
that grow beyond their usual boundaries, and which can then invade cycle. This is the reason why there are checkpoints in each phase
adjoining parts of the body and spread to other organs; the latter to stop mistakes from happening. There are three checkpoints:
process is referred to as metastasis. (1) At the end of the G1 phase: to make sure that there is nothing
• Metastases are the primary cause of death from cancer. wrong with the DNA or the cell itself
(2) During the G2 phase: to make sure that there are no problems
before mitosis begins
(3) During mitosis

BIOLOGY OF CANCER
• There are two major dysfunctions present in the process of
cancer development and these are:
(1) Defect in cell proliferation
(2) Defect in cell differentiation

NORMAL CELL PROLIFERATION

• All of our body cells are
controlled by an
• Mature normal cells are uniform in size and have a nuclei or nucleus intracellular mechanism
that are characteristic of the tissue to which the cells belong. Within that determines as to
the nucleus are chromosomes which contain the DNA. The DNA whether cell proliferation
molecules carry the genetic information that control the synthesis of is necessary. There
proteins. Genes are subunits of chromosomes and consist portion must be equilibrium
of DNA that specify the production of particular sets of protein. The which means that cell
genes control the development of specific traits, like having freckles, proliferation must be
white skin or curly or straight hair. It is the genetic code in the DNA equal with cell
of every gene that is being translated into protein structures that degeneration or death.
determine the type, maturity, and function of a cell. Any disruption • The process of cell
or mutation in a gene can result in an inaccurate blueprint that can division and proliferation
produce an aberrant cell which can be cancerous. is activated only in the
presence of cell degeneration or death (apoptosis).
• Occurs if the body has a physiologic need for more cells.
Example: When we have an infection, we are infected with a virus
or bacteria and there is a need for the body to produce more white
blood cells to fight this infection. This is the reason why there is
proliferation of more WBCs in cases of infection.
• Contact inhibition: Another means of proliferation control. It is
when normal cells respect the boundaries and territory of the cells
surrounding them. Normal cells will not invade a territory that is not
their own and you can see that in the picture above.

DEFECT IN CELL PROLIFERATION

• Cancer cells will proliferate at the same rate as the normal cells of
the tissue from which they arise. If cancer cells arise from the GI
tract, the proliferation will be fast in the same as all the other cells in
the GI tract. If they proliferate from cartilage, they will proliferate slow
like the other cells in the cartilage.
• Cancer cells respond differently from normal cells to the intracellular
signals that regulate cell proliferation and death.
• The proliferation of the cancer cells is indiscriminate and
continuous.
• G0 phase: The cell is first at its resting phase where it is not dividing • The cancer cells can produce more than two copies which can then
at all until it enters the cell cycle and goes through the four phases. lead into a tumor mass.
• G1 phase: In this phase, the cell enlarges and synthesizes protein
to prepare for DNA replication. During this phase, the cell prepares
to replicate and enters into the next phase which is the synthesis.
• Synthesis (S) phase: In this phase, DNA is replicated and the
chromosomes in the cells are duplicated.
• G2 phase: The cell will prepare itself for mitosis and with all the
when the preparation is complete, mitosis will begin.

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 DEFECT IN CELL DIFFERENTIATION
• Under normal
circumstances,
most tissues
will have a
population of
undifferentiated
cells known as
your stem
cells. The stem
cells ultimately
differentiate
and become
mature,
functioning cells of a specific tissue.
• Cell differentiation will happen in an orderly process that progresses • Dysplasia
from a state of immaturity to a state of maturity. - Represents a loss of DNA control over differentiation occurring
• Because all body cells are derived from the fertilized ova, all cells in response to adverse conditions
have the potential to perform all body functions. - Dysplastic cells show abnormal variation in size, shape and
• As cells differentiate, this potential is repressed, and the mature appearance, as well as a disturbance in their usual arrangement.
cells can perform only specific functions.
• Under normal conditions, the differentiated cell is stable and will not
dedifferentiate, or return to its previous undifferentiated state.

GENETIC LINK
• There are two types of
normal genes that
can be affected by
mutation:
(1) Protooncogenes –
promote growth
(2) Tumor suppressor
genes – suppress
growth, slow down cell
division, repair DNA
mistakes or
communicate • Anaplasia
apoptosis - It is the regression of a cell to an immature or undifferentiated
cell type
• If there is a mutation in the protooncogenes, it will influence the cell
- Anaplastic cell division is no longer under DNA control
cycle because it will increase the cell proliferation which will lead to
- Anaplasia usually occurs when a damaging or transforming event
the development of tumors.
takes place inside the dividing, still undifferentiated cell, leading to
• If there is mutation in the tumor-suppressor gene, it gets inactivated
loss of useful function. Also anaplasia may occur in response to
and lead to the development of cancer cells.
overwhelmingly destructive conditions inside the cell or in
surrounding tissue.
CELLULAR ALTERATIONS IN CELL DIFFERENTIATION
• There are adverse conditions that occur in inner body tissues during
differentiation. There are also protective adaptations that can
produce alterations in cells. Some of these alterations are helpful,
but in some other cases the cells mutate beyond usefulness and
eventually become liabilities.

CELLULAR ALTERATIONS IN CELL DIFFERENTIATION

• Hyperplasia
- There is increase in the number or density of normal cells.
- Occurs in response to stress, increased metabolic demands or
elevated levels of hormones.

DEVELOPMENT OF CANCER
• Or what we call the process of carcinogenesis.

• Metaplasia
- It Is a change in the normal pattern of differentiation such that
dividing cells differentiate into cell types not normally found in that
location in the body.
- The metaplastic cells are normal for its particular type, but it is
not in its normal location. However metaplastic cells are under 1. Initiation
normal DNA control and they are considered to be reversible when • Involves a mutation in the cell’s genetic structure
the stressor or other disruptive conditions will be removed or if they
• It can be inherited
cease.

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• It can be acquired, there is that chance that the damage cell will die elsewhere in the body. It's also important to take note that all solid
or it will repair itself. However if the cell death or repair does not tumors can metastasize. However, this is not true with liquid
occur before cell division, the cell will replicate into daughter cells cancers because they do not metastasize because in the first place
each with the same genetic alteration, thereby causing the initiated there is no primary tumor and most people who die of cancer will die
cell. because they have a metastatic tumor. This is why early diagnosis
- Acquired mutation can be caused by carcinogens: chemical, is the key here.
radiation, and virus • Cancers with good screening methods such as the screening
2. Promotion methods for breast cancer and prostate cancer increases the
• It is characterized by the reversible proliferation of the altered cells. likelihood of cure whereas those cancers which are difficult to
With promotion the activity of promoters are reversible. screen and are usually detected late and are already in the
• Example: Dietary fat, obesity, cigarette smoking metastatic stage are the ones that are most likely to cause death.

3. Progression TUMOUR INVASION

• Increased growth rate of the tumor, increased invasiveness and
metastasis.

CHARACTERISTICS OF MALIGNANT TUMORS

• Loss of regulation of the rate of mitosis – This results in rapid
cell division and growth of the neoplasm
• Loss of specialization and differentiation – Malignant cells
cannot and do not perform typical cellular functions and many of
them actually produce hormones and enzymes similar to those of
the parent tissue but usually in excessive amounts, then it can also
help reveal their presence.
• Loss of contact inhibition - Malignant cells do not respect other
cellular boundaries. They can easily invade and destroy other
tissues.
• Progressive acquisition of a cancerous phenotype - They
mutate and mutate, they become more deviant than the previous
generation. Additionally, these malignant cells seem to be immortal. • Aggressive tumors possess several qualities that facilitate invasion.
They do not stop growing and they do not die as do normal cells. 1. Ability to cause pressure atrophy – The tumor is growing bigger
Normal cells actually have a genetically determined lifespan. and the pressure of this growing tumor can cause atrophy and
• Irreversibility - The transformation into a malignant cell is necrosis of adjacent tissue. The malignancy then moves into the
irreversible or if it's going to happen that is going to be very rare that vacated space.
a malignant neoplasm will revert to a benign state. 2. Ability to disrupt the basement membranes of normal cells -
• Altered Cell Structure - If you're going to examine or do a These cancer cells can actually bind to elements of the basement
cytological examination of the malignant cells it will reveal distinct membrane and secrete enzymes that degrade physical barrier thus
differences in the cell nucleus and the cytoplasm as well as the facilitating their movement into the normal tissues and subsequently
overall cell shape that differs that of a normal cell of the particular the lymph and the blood circulation.
tissue type and that can be seen in biopsy studies in tissue studies. 3. Motility – The ability to move. Malignant cells are actually less
• Simplified Metabolic Activities - The work of the malignant cells bound to each other in comparison with your normal cells. They
is simpler than that of the normal cell. They show an increased have this reduced aggressiveness therefore they can easily
synthesis of substances needed for cell division and they have no separate from the neoplasm and therefore move into the
need to create proteins for the specialized functions of the tissues surrounding body fluids and tissues.
they divide. 4. Response to chemical signal from adjacent tissues – This is all
• Ability to promote their own survival – Like for instance, their very about chemotaxis. Normal cells actually have these products of
presence and their ability to initiate vascular permeability. Malignant cellular metabolism and these end products will act like
cells promote the development of non-new plastics trauma which is chemotherapy signals that will attract cancer cells so the mobile
actually a connective tissue framework consisting of collagen and cancer cells are now attracted to your normal cells. The tumor cells
other components which then support the neoplasm. Aside from that will now borrow through the tissue membranes of normal cells and
they also have the power to create their own blood supply and that it is where it will begin to multiply thus facilitating invasion.
is through the process called angiogenesis. Through the process
of angiogenesis, tumor cells secrete a polypeptide angiogenic METASTASIS
growth factor that stimulates blood vessels from surrounding normal
tissue to grow into the tumor. Malignant cells divert nutrition from the
host to meet their own needs. By diffusion when the tumor is less
than one millimeters and thereafter by means of the newly formed
blood vessels. They also divert nutrition or in other words they steal
nutrition from the normal cells that is why cancer patients tend to be
too skinny or malnourished because of this ability of the malignant
tumors, if they are going to be unchecked or uncontrolled of course
they have the ability also to destroy their host or cause death to their
host.

INVASION AND METASTASIS

• The two abilities of cancer cells that make them so deadly.
• These are the causes of cancer deaths.
• Invasion – Refers to the direct extension and penetration by cancer
cells into the neighboring tissues. • It is the traveling of these cancer cells from a primary tumor towards
a distant organ.
• Metastasis - came from the Greek word “methistani” which means
to move to another place and this refers to the spreading of cancer • Metastasis, it is not destiny, it's not a random thing that out of the
from primary organ site to distant organs. This describes the ability blue just happens. It is actually a very orderly process; it is a multi-
of cancer cells to penetrate into the lymphatic and blood vessels step process that is very predictable.
circulate through these systems and invade normal tissues • It begins with the rapid growth of your primary tumor. As the tumor
grows of course it's going to develop its own blood supply. This is
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 actually the process of angiogenesis. It is very critical for the cancer
cell to develop a blood supply because it is where it gets its own • If you think that the role of the immune system is just sitting there
nutrients and that is also why there are cancer drugs that inhibit this doing nothing, allowing the cancer to invade and metastasize well,
one. They are anti-angiogenesis drugs that will help shrink the well of course not. The immune system is there to protect the body.
tumor. • Our cancer cells have the ability to tell normal cells from abnormal
• Cancer cells have the ability to travel or they are very mobile. They cells. That is why if someone receive a transplanted kidney, their
can detach from the primary tumor and start invading the tissue immune system can attack that kidney because it recognizes that
surrounding the tumor and penetrate the wall of the lymph or kidney is a non-self, causes the destruction of that transplanted
vascular vessels for metastasis to the distant side. Once free from organ.
the primary tumor, metastatic tumor cells often travel to distant • The cancer cells can also be perceived as non-self by our immune
organ sites via hematogenous so in other words by your circulation system, they can elicit an immune response that can result in their
or via your lymphatic system. rejection and destruction.
• Hematogenous metastasis also involves several steps beginning • However, unlike your transplanted cells, cancer cells arise from
with the primary tumor cells penetrating blood vessels. Then of normal human cells and although they are mutated and therefore
course these tumor cells then enter the circulation travel through the they will look different. The immune response that is mounted
body and adhere to penetrate small blood vessels of distant organs. against these cancer cells may be inadequate to effectively kill
• Most of the tumor cells will not survive or will not get into it into the them.
distant organ. Some of them get destroyed by mechanical
mechanisms that is through the turbulence of blood flow. There is WHAT MAKES YOUR CANCER CELLS DIFFERENT?
our immune system, and our immune system can also destroy this • You can actually see through the representation (based from the
tumor cells. image above) cancer cells have triangular shaped antigens which is
• However, cancer cells are very witty. They are intelligent and they called as tumor associated antigens.
know how to escape the immune system and survive the turbulence • The immunologic surveillance of the body will see this (tumor-
of the blood flow. associated antigens, e.g ‘Oh this cell is kinda suspicious it does
• One way of doing so is that, they combine with tumor cells platelets not look like a normal cell’) it will tell that it does look different.
and fibrin deposits and these may protect some of the tumor cells Then the immune cells will detect and destroy these cells with
from destruction in the blood vessels. abnormal or outer antigenic determinants.
• In the lymphatic systems, tumor cells may be trapped in the first • Under normal circumstances, the immune surveillance will prevent
lymph node confronted and likely to spread from a tumor. This lymph this transformed cells from developing into clinically detectable
node is referred to as your sentinel lymph node. That is why there tumors.
is this test or this procedure called sentinel lymph node biopsy. This
can be done to help determine the extent of the cancer. A positive
SLNV test means is that cancer is present in the sentinel node
and may have spread to other lymph nodes or organs.
Sometimes, the tumor cells may also bypass local lymph nodes and
travel to a distant lymph node.

VARIOUS CANCERS AND SITES OF METASTASIS

VARIOUS CANCERS AND SITES OF METASTASIS

PRIMARY TUMOR COMMON METASTASIC
SITES
Bronchogenic (lung) Spinal cord, brain, liver, bone
Breast Regional lymph node, vertebrae,
brain, liver, lung bone
Colon Liver, lung, brain, ovary, bone
Prostate Bladder, bone, (especially
vertebrae), liver
Malignant Melanoma Liver, lung, spleen, regional
lymph nodes, brain

ROLE OF IMMUNE SYSTEM

• Cytotoxic T cells plays the dominant role of getting rid of cancer

cells. So the antigen presentation (Dendritic cell which is an antigen
presenting cell and T-Helper cell) will now release the cytokines
(inflammatory mediators) they also activate the cytotoxic T-cells.
• More Cytotoxic T-cells will get into the area and they will bind with
the cancer cell.
• As it binds with the cancer cells it is going to release granules,
lysine, peforin, and granzymes. Thereby causing the apoptosis of
the cancer cells.

THERE ARE ALSO OTHER CELLS THAT WILL HELP GET RIDE OF
THE CANCER CELLS:
o CYTOTOXIC T CELLS - play dominant role in resisting tumor
growth, can kill tumor cells
o T CELLS - are important in the production of cytokines (e.g.,
Interleukin-2 [IL-2], y-interferon), which stimulate T cells, NK cells,
B cells, and macrophages

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 o NATURAL KILLER (NK) CELLS - can directly lyse tumor cells
spontaneously without any prior sensitization. In other words, it
doesn’t need priming, it’s gonna kill the tumor cells at first sight, it’s
like heat at first sight, it’s gonna kill right away the particular tumor
cell.
o Y-INTERFERON (made by T cells) AND IL2 (released from T
cells) - stimulate NK cells, resulting in increased cytotoxic activity.
o MACROPHAGES - can be activated by y-interferon to become
nonspecifically lytic for tumor cells. Secretes cytokines, including IL-
1, tumor necrosis factor (TNF), and colony-stimulating factors
(CSFs).
o ALPHAINTERFERON (a-interferon) - augments the killing ability
of NK cells.
o TNF (Tumor Necrosis Factor) - causes hemorrhagic necrosis of
tumors and exerts cytocidal or cytostatic actions against tumor cells
o CSFs (Colony Stimulating Factors) - regulate the production of
various blood cells in the bone marrow and stimulate the function of
various WBCs. • This picture further explains that how cancer cells can disguise or
o B CELLS - can make specific antibodies that bind to tumor cells. hide itself. The tumor-associated antigen are blocking the antigens.
Because the antibodies are blocking the antigens it stops the
ONCOFETAL ANTIGENS cytotoxic T cells from interacting with the cancer cells. The cytotoxic
• Oncofetal antigens are a type of tumor antigen. They are found on t cells have a dominant role to play in killing the cancer cell or
the surfaces and the inside of cancer cells and fetal cells. causing apoptosis to the cancer cell. If there is blocking, antibodies
• These antigens are an expression of the shift of cancer cells to a will not be able to do so.
more metabolic pathway more immature metabolic pathway. This
expression is usually associated with embryonic or fetal periods of CANCER IN OLDER POPULATION
like. • Approximately 53% of cancer incidence and 69% of cancer deaths
• The reappearance of this fetal antigens is not well understood we occur in persons aged 65 years or older (ACS,2015a).
think that it is the result of cell regaining its embryonic capability to • The most commonly seen cancers in women are breast, colorectal
differentiate into many different cell types. and lung cancers, and melanoma of the skin. In men, prostate, lung
• That is why one of the ways of actually detecting cancer is detecting and colorectal cancers, and melanoma of the skin, occur most
this oncofetal antigens with the help of serologic tests. frequently.

TESTS THAT CAN BE PERFORMED TO IDENTIFY WHY ARE THE ELDERLY AT INCREASED RISK FOR DEVELOPING
ONCOFETAL ANTIGENS CANCER?
1. CEA (Carcinoembryonic antigen) - present in colorectal cancer. • At least five cycles of genetic mutations seem necessary to
2. AFP (Alpha-fetoprotein) – a tumor marker for liver cancer. cause permanent damage to the afflicted cells
3. CA-125 – Liver cancer • Long-term exposure to high doses of promotional agents is
4. CA 19-9 – Pancreatic & Gall Bladder Cancer usually necessary to allow the cancer to take hold
5. PSA (Prostate-specific antigen) – Prostate cancer • Immune response alters with ageing, its actions becoming more
6. CA-15.3 & CA 27-29 – Breast cancer generalized and less specific that free radicals (molecules resulting
from the body’s metabolic and oxidative processes) tend to
ESCAPE MECHANISMS FROM IMMUNOLOGIC SURVEILLANCE accumulate in the cells over time, causing damage and mutation
IMMUNOLOGIC ESCAPE • Hormonal changes that occur with ageing can be associated
• The process by which cancer cells evade the immune system with cancer. Postmenopausal women receiving exogenous
estrogen have an increased risk of breast and uterine cancers.
• Possible mechanisms by which cancer cells escape immunologic
surveillance include: Older men are at risk of prostate cancer, possibly due to breakdown
(1) Suppression of factors that stimulate T cells to react to of testosterone into carcinogenic forms.
cancer cells; If the T cells are not stimulated then the whole
immunologic cascade is not going to be activated, thereby causing AGE-RELATED CHANGES AND THEIR EFFECTS ON PATIENTS
the cancer cells to proliferate more. WITH CANCER
(2) Weak surface antigen allowing cancer cells to “sneak 1. Impaired immune system: Use special precautions to avoid
through” immunologic surveillance; One of the key for the infection; monitor for atypical signs and symptoms
immune system is to identify the cancer cells is via the TAAs or the 2. Altered drug absorption, distribution, metabolism and
Tumor-Associated Antigens. If they are not detected by the elimination: Mandates and careful calculation of chemotherapy
immune system, the immunologic cascade will not be activated. and frequent assessment for drug response and side effects; dose
(3) Development of tolerance of the immune system to some adjustment may be necessary
tumor antigens; it can do so by expressing molecules that can 3. Increased prevalence of other chronic diseases: Monitor for
induce the healing force lymphocyte tolerance. In immunology, effect of cancer or its treatment on patient’s other chronic diseases;
when we say tolerance, it is the state of unresponsiveness to a monitor patient’s tolerance for cancer treatment; monitor for
specific antigen. If the immune system will stop responding to these interactions with medications used to treat chronic diseases
cancer cell antigens, then the case will stop immunologic 4. Diminished renal, respiratory and cardiac reserve: Be proactive
surveillance. in prevention of decreased renal function, atelectasis, pneumonia
(4) Suppression of the immune response by products secreted and cardiovascular compromise; monitor for side effects of cancer
by cancer cells; You don’t want to suppress the immune system if treatment
a person has this cancer cell, otherwise, they are going to 5. Decreased skin and tissue and integrity; reduction in body
proliferate. mass; delayed healing: Prevent pressure ulcers secondary to
(5) Induction of suppressor T cells by the tumor; What this immobility; monitor skin and mucous membranes for changes
suppressor T cells do is that they normally assist in regulating related to radiation or chemotherapy; monitor nutritional status
lymphocyte production and therefore diminishes immune response. 6. Decreased musculoskeletal strength: Prevent falls; assess
So, the antibody production is going to be diminished. There’s going support for performing activities of daily living in home setting;
to be less soldiers against these cancer cells. encourage safe use of assistive mobility devices
(6) Blocking antibodies that binds TAAS, thus preventing their 7. Decreased neurosensory functioning; loss of vision, hearing
recognition by T cells (have the ability to disguise itself) and distal extremity tactile senses: Provide instruction modified
for patient’s hearing and vision changes; provide instruction
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 concerning safety and skin care for distal extremities; assess home
for safety
8. Altered social and economic resources: Assess for financial
concerns’ living conditions’ resources for support
9. Potential changes in cognitive and emotional capacity: Provide
education and support modified for patient’s level of functioning and
safety

HEALTH EDUCATION FOR THE ELDERLY AND FAMILY

• Discuss signs and symptoms of cancer
• Stress the importance of seeking healthcare if any of the warning
signs develop
• Stress the importance of having an annual physical examination
• For women, teach how to perform a monthly breast self-exam (BSE)
and emphasize the importance of continuing BSE and regular
mammography, available free from age 40 onwards
• Teach men the early signs of prostate cancer and encourage them
to have an annual digital rectal exam

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 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 2
BREAST CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 22 2021
TRANSCRIBED BY ZARAHTESS RUBIO AND TOM CUENCA

o The use of combined hormone therapy, such as the estrogen

BREAST CANCER plus progesterone will actually increase the risk of breast
• Did you know that every minute, somewhere in the world, a woman cancer. Also, the risk of having a larger and more advanced
dies from breast cancer? More than 1,400 of women every day. breast cancer at diagnosis.
Being a woman will always be at risk to breast cancer, however, the 4. Family history
same is not true for men because a man's lifetime risk of breast o Especially breast cancer in a first degree relative.
cancer is only about 1 in 1,000. The good thing though is that, breast 5. Genetic factors
cancer deaths have been declining since the 1990 and that is thanks o There are genetic factors including gene mutations, mutations
to early detection, better screening, increased awareness, and new in the BRCA (breast cancer) Type, and the BRCA Type 2 will
treatment options. play a role in 5%-10% of breast cancer cases
• Breast cancer is actually a disease in which cells in the breast grow 6. Personal history of breast cancer, colon cancer, endometrial
out of control, however, there are different kinds of breast cancer cancer, and ovarian cancer
and the kind of breast cancer will depend on which cells in the breast o If you had breast cancer before or you had colon cancer, and
turn into cancer. these other types of cancer also increases the risk of having
breast cancer or breast cancer again.
ANATOMY AND PHYSIOLOGY OF THE BREAST 7. Early menarche (before age 12), late menopause (after age 55)
o This means that the woman has a long menstrual history and
it is this long menstrual history that increases the risk of breast
cancer.
8. First full-term pregnancy after age 30, nulliparity (having no
child at all)
9. Benign breast disease with atypical epithelial hyperplasia,
lobular carcinoma in situ.
o These atypical changes in the breast biopsy increases the risk
of breast cancer as well.
10. Weight gain and obesity after menopause
o Fat cells will store estrogen which increases the likelihood of
developing breast cancer
11. Exposure to ionizing radiation
o The radiation will damage the DNA, thereby leading to
• Breast is actually made up of three main parts: mutations and mutations will lead to cancer.
1. Lobules – are the glands that produce the milk. 12. Alcohol consumption
2. Ducts – are the ones that carry the milk into the nipples that o Women who drink more than one alcoholic beverage per day
is why the direction of the ducts are going towards the nipples. have an increased risk of breast cancer
3. Connective Tissue – are mostly consisting of the fibrous and 13. Physical inactivity
the fatty tissue, and they surround and hold everything o Breast cancer risk is decreased in physically active women.
together.
• Breast cancer can begin in different parts of the breast, and the kind PATHOPHYSIOLOGY OF BREAST CANCER
of breast cancer depends on which of these cells or parts in the
• A family history of breast cancer is an important risk factor for this
breast can turn into cancer. disease especially if the involved family member also had ovarian
cancer, was pre-menopausal, had bilateral breast cancer, or is a
RISK FACTORS OF BREAST CANCER FOR WOMEN
first degree relative. First degree relative means that it could be the
• It is important to take note that the etiology of breast cancer is not mother, sister, or a daughter.
completely understood, there number of risk factors that are related • Having any first degree relative with breast cancer increases a
to breast cancer, however, there are these risk factors appear to be woman's risk to breast cancer. According to studies, about 5% to
cumulative and they are also interacting, therefore, the very 10% of all breast cancers are actually hereditary, this means that
presence of multiple risk factors may greatly increase the overall risk there is a specific genetic abnormality that contributes to the
especially for people with a positive family history. development of breast cancer and this has been inherited or passed
DIFFERENT RISK FACTORS AMONG WOMEN from parent to child.
• With breast cancer, most inherited cases are associated with
1. Female mutations in your two genes:
o Women are at far greater risk than men with 99% of breast 1. Breast Cancer (BRCA) 1 – is located in the chromosome 17
cancers occurring in women. 2. Breast Cancer (BRCA) 2 – is located in your chromosome 13
2. Age
o Increasing age also increases the risk of developing breast
cancer. The incidence of breast cancer in women under 25
years of age is very low, but it increases gradually until
age 60, and after age 60, the incidence just continued to
increase dramatically.
3. Hormone use
o Hormonal regulation of the breast is related to the
development of cancer, however, the mechanism as to how
this happens is poorly understood.
o The hormone estrogen and progesterone may act as tumor
promoters to stimulate breast cancer growth if malignant
changes in the cells have already occurred. It could be related
to the presence of the progesterone and estrogen.
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 BREAST CANCER GENES NON-INVASIVE BREAST CANCER
• Tumor suppressor genes that inhibit tumor development when [ DUCTAL CARCINOMA IN SUTI (DCIS) ]
functioning normally. If they are not functioning well, they will not be
able to suppress the tumors, therefore, it could lead to cancer.
• There are other genes that can be a culprit of the breast cancer:
1. p53
- The p53 also inhibits tumor development when functioning
normally.
2. ATM
- This gene helps to repair damage deoxyribonucleic acid
(DNA), the damage in DNA can lead to cancer. If the DNA is
not repaired through the help of this gene, that could lead to
cancer.
3. CHEK2
- Stops tumor growth and a mutation of this one will lead to
cancer. • Characterized by the proliferation of malignant cells inside the milk
• Most people who develop cancer do not inherit an abnormal breast ducts without invasion into the surrounding tissue.
cancer gene and they do not have a family history of breast cancer, • DCIS does not metastasize and a woman generally does not die
only 5%-10% of breast cancer is hereditary. of DCIS unless it develops into invasive breast cancer. It can
actually develop into breast cancer if left untreated
RISK FACTORS OF BREAST CANCER FOR MEN • 14% to 53% of untreated DCIS can progress to invasive breast
1. Hyperestrogenism cancer over a period of 10 years.
2. Family history of breast cancer
3. Radiation exposure INVASIVE (INFILTRATING DUCTAL CARCINOMA
4. Presence of abnormal BRCA genes

• The risks in men are not as increased as the women. Males can
also have breast cancer that is why a thorough examination of the
male breast should also be a part of the physical examination.
• Men in BRCA-positive families may consider genetic testing as well
and it is also important to take note that men with an abnormal
BRCA gene can also have an increased risk of developing prostate
cancer.

PREVENTION OF BREAST CANCER • This is the most common type of breast cancer.
• It starts in the milk duct and then it breaks through the wall of the
duct, invading the surrounding tissue. From there, it may
metastasize to other body parts

TYPES OF INVASIVE (INFILTRATING) DUCTAL CARCINOMA

1. Medullary carcinoma
• Most frequently occurs in women in their late 40s and 50s
• Manifesting with cells that resemble the medulla of the brain
• Tumors grow in a capsule inside a duct
1. Prophylactic Oophorectomy • Favorable Diagnosis/Prognosis
o This is the removal of the ovaries. This is specifically for 2. Colloid carcinoma
women with BRCA 1 or BRCA 2 mutation, specifically also for • Presents in women who are menopausal and over 75 years old
pre-menopausal women • Mucin producer, the tumor grows slowly
o This one will decrease the risk of breast cancer and • Prognosis is favorable
ovarian cancer in pre-menopausal women. 3. Inflammatory breast cancer
o It is because our ovaries are our main sources of estrogen, in • An aggressive type of breast cancer and this one has a high
a pre-menopausal woman. Removing it will lower the risk of risk of metastasis
breast cancer • Characterized by diffuse edema and erythema of skin, often
2. Prophylactic Mastectomy referred to as peau’ d’orange. Breast will look red, feel warm,
o This reduces the risk of developing breast cancer by 90% and has a thickened appearance or orange peel (refer on the
to 95% in women with BRCA mutation. picture below). Sometimes, the breast develops ridges and
o Mastectomy is the removal of the breast. small bumps that look like hives.
• Cause by malignant cells blocking the lymph in the channels in
TYPES OF BREAST CANCER
the skin
1. Non-Invasive Breast Cancer – 20%
• A mass may or may not be resent
- Ductal carcinoma in situ
- Lobular carcinoma in situ
2. Invasive (Infiltrating) Ductal Carcinoma – 70-75%
- Medullary – 15%
- Tubular – 2%
- Colloid – 1-2%
- Inflammatory – 1-3%
- Paget’s Disease – 1%
3. Invasive (Infiltrating) Lobular Carcinoma – 5-10%

2
4. Paget’s Disease 5. Redness or rash
• Symptoms typically include a scaly, erythematous pruritic lesion of 6. Lumps in the armpit
the nipple. It is only in rare cases wherein the cancer is confined to 7. Nipple inversion
the nipple in itself. Page’s disease will usually have an underlying 8. Lump
ductal carcinoma. • Breast cancer is usually painless but there are some women who
• If no lump can be felt in the breast tissue and biopsy shows DCIS report a burning or stinging sensation.
without invasion, the prognosis is very favorable. • Many women with breast cancer have no symptoms and their
• The diagnosis of this can be confirmed by a pathologic examination tumors are detected only by mammography, however, most breast
of the lesion, also there are times when this type of cancer can be cancers are found by women themselves through breast self-
misdiagnosed as dermatitis that is why sometimes the diagnosis examination and by their partners during sexual activity.
of bad Paget's disease will be delayed.
DIAGNOSTIC TESTS OF BREAST CANCER
1. Clinical Breast Examination (CBE)
o Detects palpable masses
2. Mammography
o Can detect breast tumors 2 years before they reach palpable
sizes
3. Magnetic resonance imaging (MRI)
o It is used for young women who are at risk of breast cancer
4. Percutaneous needle biopsy
o Define a cystic mass or fibrocystic changes and provide
specimens for cytological examination breast biopsy
5. Aspiration biopsy or fine-needle aspiration biopsy
o A needle is used to remove cells or fluid from the breast for
cytological examination
INVASIVE LOBULAR CARCINOMA 6. Sentinel Lymph Node Biopsy
o Helps to identify sentinel lymph nodes which are lymph nodes
that drain first from the tumor site.
o If the sentinel lymph nodes (SNLs) are negative, no further
axillary surgery is needed.
o If the sentinel lymph nodes (SNLs) are positive, a complete
axillary lymph node dissection (ALND) may be done

• Tumors arise from the lobular epithelium and typically occur as an

area of ill-defined thickening of the breast. POSTMASTECTOMY COMPLICATIONS OF BREAST CANCER
• Often multicentric and can be bilateral. 1. Lymphedema
• In invasive lobular carcinoma, the cancer cells can break out of - An accumulation of lymph in soft tissue which can occur
the lobule and have the potential to metastasize to other areas of because of the lymph node sampling procedure or radiation
the body. therapy
- Signs and symptoms include:
CLINICAL MANIFESTATIONS OF BREAST CANCER a. Heaviness
b. Impaired motor function in the arm
c. Numbness and paresthesia of the fingers
- Cellulitis and progressive fibrosis of the skin which can result
from untreated lymphedema
2. Post-Breast Therapy Pain Syndrome
- The most common theory is that PBTPS results from injury to
the intercostobrachial nerves
- Common symptoms include:
a. Chest and upper arm pain
b. Tingling down the arm
c. Continuous aching and burning
d. Numbness
e. Shooting or pricking pain
f. Unbearable itching that persists beyond the normal 3-month
healing time
g. Edema
- Treatments include:
a. Nonsteroidal anti-inflammatory drugs (NSAIDS)
1. Texture change b. Low-dose antidepressants
2. Dimpling c. Topical anesthetics (e.g., EMLA [lidocaine and prilocaine]),
3. Lymph discharge and antiseizure drugs (e.g., gabapentin)
4. Bloody discharge 3. Phantom Breast Pain

3
 - Phantom breast pain is feeling pain in the breast after breast PREOPERATIVE CARE
was removed via mastectomy or lymph amputations • Provide the patient with enough information to insure informed
- The brain continues to send signals to nerves in the breast consent. These include:
area that were cut during surgery even though the breast is no 1. Instructions on pain control and what to expect after surgery (e.g.,
longer physically there dressing and drain care, turning, coughing, and deep breathing)
4. Breast Reconstruction 2. A review of mobility restrictions and postoperative exercises
- Phantom breast pain is feeling pain in the breast after breast 3. An explanation of the recovery period
was removed via mastectomy • Help to evaluate the advantages and disadvantages of the options,
provide information relevant to the decision, clarify unresolved
MEDICAL MANAGEMENT OF BREAST CANCER issues with the health care provider, and support the patient and
1. Chemotherapy family once the decision is made
- Tamoxifen citrate (Nolvadex) is an oral medication that • Teach the patient and family, with a return demonstration, how to
interferes with estrogen activity. manage drains at home. Most patients are discharged from the
- Common combination-therapy protocols in the adjuvant and hospital 24-48 hours after a mastectomy, depending on if
neoadjuvant setting are: reconstructive surgery was done.
(1) CMF: cyclophosphamide, methotrexate and fluorouracil • The drains remove the excess puss, blood or other fluids and
(2) AC: doxorubicin and cyclophosphamide with or without the prevents these fluids in accumulating in the body.
addition of a taxane, such as paclitaxel (Taxol) or docetaxel
(Taxotere)
(3) CEF or CAF: cyclophosphamide, epirubicin (Ellence) or
doxorubicin, and fluorouracil
- Adverse effects of tamoxifen (imp ones) include:
a. Cataract
b. Hot flushes
c. Endometrial cancer
d. Thromboembolism
2. Immunotherapy
- Using trastuzumab (Herceptin) is used to stop the growth of
breast tumors that express the HER2/neu receptor (which
binds an epidermal growth factor that contributes to cancer
cell growth) on their cell surface. DISCHARGE INSTRUCTIONS
3. Radiation Therapy • Teach the patient and family, with a return demonstration, how to
- It is administered by means of an external bream or tissue manage drains at home. Most patients are discharged from the
implants hospital 24-48 hours after a mastectomy, depending on if
a. Intraoperative Radiotherapy reconstructive surgery was done.
o External beam radiation is used and high intensity
• Arm and shoulder exercises which are started gradually may begin
x-ray is beamed through several angles of the breast prior to discharge
o Brachytherapy (internal radiation therapy) is done
• Discomfort can be minimized by giving analgesics regularly when
where radiation is delivered through catheters in the
the patient is in pain and about 30 minutes before starting exercises
breast.
• When the patient can shower, the warm water on the involved
o A probe is inserted into the cavity created by the
shoulder often relaxes the muscle and reduces joint stiffness
lumpectomy and radiation equivalent to 6 weeks of
doses is emitted for about 25 minutes • Explain the specific follow-up plan to the patient and emphasize the
importance of ongoing monitoring and self-care
SURGICAL MANAGEMENT OF BREAST CANCER • Teach the patient to report symptoms, such as fever, inflammation
1. Radical Mastectomy at the surgical site, erythema, and unusual swelling. Other changes
to report are new back pain, weakness, shortness of breath, and
- It is the removal of the entire affected breast, the underlying
chest muscles and the lymph nodes under the arms change in mental status including confusion.
2. Simple Mastectomy
- It is the removal of the complete breast only.
3. Segmental Mastectomy or Lumpectomy
- It is the removal of the tumor and the surrounding margin of
breast tissues.
4. Modified Radical Mastectomy
- It is the removal of the breast tissue and lymph nodes under
the arm (axillary node dissection) leaving the chest wall and
muscle intact
5. Breast Reconstruction
- Breast implant is inserted under the pectoris muscle
- Latissimus dorsi musculocutaneous flap

SURGICAL MANAGEMENT OF BREAST CANCER

PROVIDE PSYCHOLOGICAL SUPPORT
• Provide a safe environment for the expression of feelings
• Identify sources of support and strength, such as the partner, family
and spiritual or religious practices
• Encourage the patient to identify and learn personal coping
strengths
• Promote communication among the patient, family and friends
• Answer questions about the disease, treatment options and
reproductive, fertility or lactation issues (if appropriate)
• Make resources available for mental health counseling
• Offer information about local and national community resources

4
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 3
LUNG CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 22 2021
TRANSCRIBED BY AYESSA VILLAMOR AND AUBREY MONTA

LUNG CANCER CLASSIFICATIONS OF LUNG CANCER

• Cancer of the lungs take more lives every year than breast, colon 1. Small cell lung cancer (SCLC) - accounts to 15%
and prostate cancer combined. • Small cell lung cancer
• 81% of those living with lung cancer are over the age of 60 • Combined small cell
• Survival rate of lung cancer is 17% which is drastically lower than
breast cancer with a survival rate of 90% and prostate with nearly Cell Type and Presentation and Spread
100% Prevalence Associated
• Only 15% of lung cancer are caught in an early stage and when it Manifestations
has spread to other organs the survival rate drops to 3.5& • Small cell • Central lesion with • Aggressive
• Smoking is responsible for roughly 90% of all cases of lung cancer carcinoma hilar mass common, tumor; more
(18%) early mediastinal than 40%
RISK FACTORS OF LUNG CANCER • Small cell involvement, no people have
1. Tobacco smoke - risk of developing lung cancer is 23 times higher lung cavitation; SIADH, distant
in male smokers and 13 times higher in female smokers compared cancer Cushing’s syndrome, metastasis
to life-long non-smokers • Combined thrombophlebitis
2. Electronic cigarettes - this is a formed of electronic nicotine small cell
delivery system it’s not still clear about how safe it is to inhale some
substances in the vapor. 2. Non-small cell lung cancer (NSCLC) - 85%
3. Secondhand smoke • Squamous cell (20%)
4. Environmental and occupational exposure (radon, asbestos, • Large cell (5%)
arsenic) - exposure to pollutants like a motor vehicle, emissions, • Adenocarcinoma (38%)
from the factory of occupational exposure. • Other which cannot be classified (18%)
5. Genetic Mutation (TP53 or p16) - can cause certain changes in the
DNA of the lung cells, if there are acquired changes in genes such Cell Type and Presentation and Spread
as the tp53 or p16 and these are tumor suppressor genes and if Prevalence Associated Manifestations
there are mutations to such genes of course that could also • Non-small • Central lesion located in • Spreads
predispose a person to lung cancer. cell the large bronchi; by local
carcinoma person presents with invasion
PATHOPHYSIOLOGY OF LUNG CANCER (85%) cough, dyspnea,
• Squamous atelectasis and
cell wheezing; hypocalcemia
carcinoma common
(29%)

Cell Type and Presentation and Associated Spread

Prevalence Manifestations
• Non-small • Usually, peripheral lesion • Early
cell that is larger than that metastasis
carcinoma associated with
(85%) adenocarcinoma and tends
• It all started with a normal epithelium because most of the lung
• Large cell to cavitate; gynecomastia,
cancers arise from normal epithelium and it all starts with the
carcinom thrombophlebitis
exposure to the carcinogen so the carcinogen will bind to the DNA
and in the process of binding to the DNA, it causes cell damage to a (9%)
the DNA. This damage will result in cellular change, abnormal cell
growth and eventually a malignant cell so there is going to be Cell Type and Presentation and Associated Spread
molecular change or cellular changes that’s going to happen. Then, Prevalence Manifestations
cells go through cell cycle, the damage DNA is going to be passed • Non-small • Peripheral mass involving • Early
on to daughter cells, the DNA will undergo further changes and will cell bronchi, few local symptoms; metastasis
become unstable. Of course, with the accumulation of these carcinoma hypertrophic pulmonary to CNS,
changes, Pulmonary epithelium undergoes malignant (85%) osteothropathy skeleton
transformation from normal epithelium eventually to invasive • Adenocar and
carcinoma. cinomas adrenal
(32%) glands
1. Carcinogen binds to and damages the cell’s DNA
2. Cellular changes, abnormal cell growth, and eventually a
malignant cell
3. As the damaged DNA is passed on to the daughter cells, the
DNA undergoes further changes and become unstable
4. Pulmonary epithelium undergoes malignant transformation
from normal epithelium eventually to invasive carcinoma

1
 CLINICAL MANIFESTATIONS OF LUNG CANCER DIAGNOSTIC FINDINGS
• Most frequent symptoms: Cough or change in chronic cough, 1. Sputum Cytology - show presence of the malignant cells. The
hemoptysis sputum is collected on arising in the morning and if malignant cells
• Result of airway obstruction: Wheezing and shortness of breath are found in the sputum more expensive and invasive examinations
• Dull, aching chest pain occurs as the tumor spreads to the may be unnecessary.
mediastinum. 2. Bronchoscopy - is frequently done to visualize and obtain tissue
• Pleuritic pain occurs when the pleura is invaded for biopsy from the tumor.
• Hoarseness and/or dysphagia indicate pressure of the tumor on 3. CT scan - is used to evaluate and localize tumors, particularly
the trachea or esophagus tumors in the lung parenchyma and pleura.
• Systemic and paraneoplastic manifestations of lung cancer: 4. Biopsy - may be done by aspirating um fluid from a pleural effusion,
Weight loss, anorexia, fatigue and weakness; bone pain, and also through percutaneous needle biopsy and lymph node
tenderness and swelling; clubbing of the finger and toes and various biopsy
endocrine, neuromuscular, cardiovascular and hematological 5. FBS, liver function studies and serum electrolytes including
symptoms. calcium - are obtained to evaluate for evidence of metastatic
disease or neoplastic syndromes.
6. Tuberculin Test (PPD) – is performed to rule out tuberculosis as
COMPLICATIONS OF LUNG CANCER
the cause of symptoms and abnormalities seen on the chest x-ray
• Superior vena cava syndrome - partial or complete obstruction of 7. Respiratory function tests (RFTs) and ABGs – may be performed
the superior vena cava, is a potential complication of lung cancer, prior to the initiation and treatment if the person has manifestation
particularly when the tumor involves the superior mediastinum or the of respiratory insufficiency (dyspnea, activity intolerance and low
mediastinal lymph nodes oxygen saturation levels).
o Signs and symptoms: edema of the neck and face,
• At the time of diagnosis your cancer of the lung is typically already
headache, dizziness, vision disturbances and syncope, LOC
well advanced, with distant metastasis present in 55% percent of
changes, laryngeal edema
people and regional lymph nodes involvement in another 25%.
• Paraneoplastic syndrome - set of signs and symptoms that occur prognosis is generally poor: overall 5 year survival rate is only
in people with a cancerous tumor and it’s because this malignant 13% for males and 17% for females (Cancer Council, 2015).
tumor would release a substance because it could be hormone it
could be a protein which could affect a certain body system or it
STAGES OF LUNG CANCER
could also be that the body’s immune system will release a
substance that could be an antibody which is supposed to be meant
to kill the tumor but then it also damages the healthy body cells so Stage 1
in other words there is an autoimmune response. So, what we have • Tumor is 1cm-4cm.
here is hormones, so the cancer cells or malignant tumors would Disease has not spread
release hormones that would affect or cause symptoms on the (metastasized outside of
patient the lung).
• Thrombosis - lung tumors may also produce pro-coagulation
factors, increasing the risk of venous thrombosis, pulmonary
embolism and thrombotic endocarditis

EXAMPLE

Stage 2
• Tumor is 3-7cm. Disease
can be in lymph nodes, but
not in distant parts of the
body.

Stage 3
• Tumor is 3cm to more than
7cm. Disease can be in
more than 1 lymph nodes,
but not in distant parts of
the body.

Stage 4
• Cancer is in distant parts of
the body.

2
 MEDICAL MANAGEMENT 4. PALLIATIVE THERAPY
1. SURGERY • Provide radiation therapy to shrink the tumor to provide pain
• Surgical resection is the treatment of choice in NSCLC stages relief
1 to 3 without the mediastinal involvement • A variety of bronchoscopic interventions to open a narrow
• Resection gives the best chance for a cure bronchus or airway. (The growth is causing an obstruction on
• Surgery is generally not done for Small Cell Lung Cancer the bronchus. That’s why applying stent is needed to keep the
(SCLC) because of its rapid growth and dissemination at the airway as much as possible)
time of diagnosis • Pain management and other comfort measures.
• Unfortunately, most tumors are inoperable or only partially
resectable at the time of diagnosis (because of late stage) NURSING MANAGEMENT
• The type of surgery performed depends on the location and HEALTH PROMOTION
the size of the tumor as well as the person's pulmonary and • Modeling healthy behavior by not smoking
general health. • Promoting smoking cessation programs
• The goal of surgery is to remove all involved tissue while • Actively supporting education and policy changes related to
preserving as much functional lung as possible smoking

a) Laser Bronchoscopy MANAGING SYMPTOMS

Description: A bronchoscopy guided laser used to resect the • The nurse educates patient and family about the potential side
tumor. effects of the specific treatment and strategies to manage them
Indication: Tumors that are localized in a main bronchus
• Strategies for managing such symptoms as dyspnea, fatigue,
b) Thoracotomy nausea and vomiting, and anorexia help the patient and family cope
Description: Incision into the chest wall with therapeutic measures
Indication: access the lung and thoracic cavity for surgery
c) Wedge Resection
RELIEVING BREATHING PROBLEMS
Description: removal of a small section of the peripheral lung
tissue • Teaching deep breathing exercises
Indication: small, peripheral lung tumors • Chest physiotherapy
d) Segmental Resection • Directed cough
Description: removal of an individual bronchus broncho- • Suctioning
vascular segment of a lobe • Bronchodilator medications
Indication: peripheral lung tumors with no evidence of • Positioning (Fowler’s or tripod position)
extension to the chest wall or metastasis • Supplemental oxygen
e) Lobectomy • Intubation (if necessary)
Description: Removal of single lobe
Indication: tumors confined to a single lobe PROVIDING PSYCHOLOGICAL SUPPORT
f) Pneumonectomy • Identification of potential resources for the patient
Description: removal of an entire lung • Help the patient and family deal with the following:
Indication: tumor widespread throughout the lung involving the a. Poor prognosis and relatively rapid progression of this disease
main bronchus or fixed to the hilum b. Informed decision making regarding the possible treatment
options
2. RADIATION THERAPY Methods to maintain the patient’s quality of life during the course of
• May be used as treatment both for your non-small cell lung this disease
carcinoma and as well as your small cell lung carcinoma.
• May be given as curative therapy, palliative therapy (to relieve
symptoms), adjuvant therapy in combination with surgery,
chemotherapy or targeted therapy.
• relieves symptoms of dyspnea and hemoptysis from bronchial
obstructive tumors and treats superior vena cava syndrome
• it can treat pain from metastatic bone lesions or brain
metastasis

3. CHEMOTHERAPY
• Chemotherapy it is the main treatment of choice for small cell
lung cancer (SCLC). In NSCLC, chemotherapy may be used
in the treatment of non-resectable tumors or as adjuvant
therapy to surgery
• Chemotherapy for lung cancer typically consists of
combinations of two of the following drugs:
- Etoposide (VP-16), carboplatin, cisplatin, paclitaxel (Taxol),
vinorelbine (Navelbine), docetaxel (Taxotere), gemcitabine
(Gemzar), and pemetrexed (Alimta)

a) Targeted Therapy
• Targeted therapy uses drugs that block the growth of
molecules involved in specific aspects of tumor growth
(because this type of therapy just would just inhibit the
growth rather than actually killing your cancer cells.)
Targeted therapy is less toxic than chemotherapy
• Tyrosine kinase inhibitors - block the signals for growth
in your cancer cells
Example: Cetuximab (Erbitux), erlotinib (tarceva)
• Angiogenesis Inhibitors - used to treat lung cancer by
inhibiting the growth of new blood vessels. Thereby,
targeting your vascular endocellular growth factor
Example: Crizotinib (Xalkori), brigatinib (Alunbrig).
3
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 4
CERVICAL CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 29 2021
TRANSCRIBED BY AUBREY MONTA & JERWEN JULIO

CERVICAL CANCER • Receiving HPV immunization (can be given as early as 9 years

• It is a cervical cancer, the fourth most common cancer in women in old. However, those women who are aged 26 and above are not
2018. Estimated 570,000 women were diagnosed with cervical already recommended to get the vaccination
cancer worldwide and about 311 000 women died from the
disease. (WHO). STAGES OF CERVICAL CANCER
• In the Philippines, cervical cancer is the second leading cancer site
among women 7,277 cases that occur every year and around
3807 actually die because of cervical cancer.

ANATOMY OF THE CERVIX

Stage I
• The carcinoma is strictly confined to the cervix in C2

Stage II
• The carcinoma is invading beyond the uterus but the pelvic wall or
vagina
Stage III
• The tumor is now spreading to the pelvic wall or the vagina and
• Cervix is located at the bottom of the vagina and it acts like a door can even cause hydronephrosis of the kidney.
towards the uterus also known as neck of the womb. Stage IV
• The cervix is the one that is needed to prevent your pre-term labor • The tumor has extended beyond the pelvis and the bladder or the
and also the one that keeps the body to dilate at the right time and rectum. There is already a metastasis and an indicative of poor
enable the child to be born. prognosis.

RISK FACTORS OF CERVICAL CANCER DIAGNOSTIC FINDINGS OF CERVICAL CANCER

1. Chronic cervical infection 1. Pap-smear
2. Early child bearing • Identify cervical cancer microscopically in its early stages
3. Exposure to diethylstilbestrol in utero 2. Pelvic Examination
4. Exposure to human papillomavirus, type 16 and 18 (considered to • May reveal a large reddish growth or a deep ulcerating lesion. A
be a viral carcinogen) vaginal speculum is inserted to view the cervix.
5. Family history of cervical cancer
6. HIV infection and other causes of immune deficiency CLINICAL MANIFESTATIONS OF CERVICAL CANCER
7. Low socioeconomic status EARLY CERVICAL CANCER
8. Nutritional deficiencies - it has been found out that the folate • Often asymptomatic. Even there are symptoms, the woman may
beta carotene and vitamin C levels are actually lower in women not able to notice it because the usual symptoms would be a thin
with cervical cancer than in women who don’t have cervical cancer watery vaginal discharge and it is notice after intercourse or
9. Overweight status douching
10. Prolonged use of oral contraceptives
11. Sex with uncircumcised men ADVANCE CERVICAL CANCER
12. Multiple sex partners • Vaginal discharge gradually increases and becomes watery and,
13. Early age (<20 years) at first coitus finally, dark and foul smelling from necrosis and infection.
14. Sexual contact with men whose partners had cervical cancer • Vaginal bleeding which occurs at irregular intervals between
smoking and exposure to secondhand smoke periods or after menopause, may be slight and occurs usually after
mild trauma or pressure (like for instance after sex if there is
PREVENTIVE MEASURES bleeding).
SCREENING TESTS
1. Regular pelvic Examinations
2. Pap tests
• This can be done for all women especially older women past the
child bearing age

PREVENTIVE COUNSELING
• Delaying first intercourse
• Avoiding HPV infection
• Engaging only in safe sex
• Ceasing smoking
1
 MEDICAL MANAGEMENT the lab to evaluate exactly what was there so we know exactly
EARLY STAGE what we treated unlike the cryotherapy which destroys the
1. Cryosurgery – compressed nitrogen gas will flow to cryo-probe abnormal cells but doesn't allow us to have anything to evaluate to
making the metal cold enough to freeze and destroy the cervical make sure we know what we were destroying.
tissue. The tissues including the abnormal cells is frozen thereby
destroying it and the tissue will grow back and is going to be HEALTH TEACHINGS AFTER SURGERY
normal. In most cases, all abnormal cells are already removed with • Refrain from sexual intercourse
one treatment. • Do not use tampons
• Do not douche
• Take showers rather than bath tubs
• Avoid lifting heavy objects
• Report a fever or any heavy vaginal bleeding or foul-smelling
drainage which are indicative of infection

INVASIVE STAGE

2. Leap/Loop electrosurgical excision procedure – treating

abnormal cells on the cervix after an abnormal pap smear has
been evaluated. The process for a leap procedure is very similar to
a pap smear again we're in the same office that we are for a pap
but just a different room our procedure room. The copascope
which is the microscope to be able to look through to evaluate the
cervix and identify exactly where the abnormal cells are.
• Prior to doing the leap procedure, we'll give lidocaine or numbing
medication to prevent any pain during the procedure. the 1. Conization - removing a cone-shaped portion of the cervix.
procedure itself is usually quite quick i tell patients it's kind of an in • This is usually performed to treat microinvasive carcinoma
over out and that's the whole specimen and the loop is literally a especially when colposcopy cannot define the limits of
small wire loop through which electricity goes in order to allow invasion. It can be done as a form of treatment because the
cutting and prevention of bleeding at the same time. cancerous tissue has been removed. Also, it can be used as
• We have multiple different sizes of that loop that we can tailor it to a diagnostic tool because the tissue that has been removed
the size and shape of the cervix but there are situations in which can actually be sent to the lab for biopsy and it serves as um
one needs to tailor the procedure even more to the specific size a treatment
and shape of the abnormal cells or the cervix in which case one 2. Potential Complications: hemorrhage and uterine perforation.
can do what's called a cold knife colonization. that's a procedure • A sign that the client is having hemorrhage is when the
that is done in the operating room the patient is asleep instead of patient has symptoms of shock right. Uterine perforation, on
having just the local anesthetic and the cold knife part is because a the other hand, is related to peritonitis in which the client is
scalpel is used not electricity and so with the scalpel, I can get very going to have symptoms of your peritonitis
precise and do any size or shape of excision or removal of the
abnormal cells. MICROINVASIVE STAGE
WHEN IS IT USED?
• Leap procedure can be used really in two basic circumstances:
(1) If we followed up abnormal cells that have been there for at
least two years and haven't resolved because actually most mildly
abnormal cells will go away on their own about two-thirds of the
time but if they're persistent then we know over once they've lasted
those two years, they're unlikely to go away so then we can treat
them to prevent them from having the opportunity to become
worse and eventually become cancer that's one circumstance in
which we might use it.
(2) If initially we see that it's moderate or severe then we know
those cells are less likely to go away more likely to persist or
worsen and so then that's it's appropriate to treat them right up • Total Hysterectomy – is the removal of the cervix and body of the
front uterus but the fallopian tubes and ovaries are spared.

OUTCOMES
• Outcomes are excellent most of the time the cells are removed
and they do not recur but we always follow up with ongoing
surveillance with pap smears and HPV testing. I would say the
leap procedure is favored over cryotherapy because it has a
broader range of situations in which it's appropriate. So, it can be
used in mild moderate and severe disease where the cryotherapy
or freezing would be preferred in the mild disease only and the
leak procedure allows us to have a sample of the tissue to send to
2
 PELVIC EXENTERATION RADIATION THERAPY
• The removal of all pelvic contents including the bowel, vagina, and
bladder.
• Performed if the cancer recurs without involvement of the
lymphatic system. This is the last attempt of a cure.

1. Teletherapy – otherwise known as external beam radiation in

which the source of the radiation is from a machine. It is like
getting a regular x-ray. However, the radiation dose is going to be
stronger and it is aimed at the cancer cells.

TYPES OF PELVIC EXENTERATION

1. Anterior exenteration
• It is the removal of the uterus, ovaries, fallopian tubes,
vagina, bladder, urethra, and lymphatic vessels and nodes.
• An ileal conduit is created for excretion of urine. It is a stoma
where urine is to be excreted. It is created because one of
the organs that has been removed is the bladder and
urethra.
2. Posterior exenteration
• It is the removal of the uterus, ovaries, fallopian tubes, bowel
and rectum.
• A colostomy is created for excretion of feces because the
bowel and the rectum were removed. It is where the
excretion of the feces is to be now. We have to provide
health teaching regarding this contraption and how to take
care of them.

2. Brachytherapy - known as your intracavitary radiation therapy,

the radiation source is placed in a device in the vagina and
sometimes in the cervix. It is mainly used in combination with the
tele. It is rare that the brachytherapy is used alone.

3
 NON-SURGICAL MANAGEMENT • Monitor for evidence of fistula formation and teach the woman
to do the same. Because it is a potential complication of radiation
CHEMOTHERAPY
to the pelvic or abdominal cavities. A fistula is an abnormal
• This is mostly given/used for tumor that cannot be removed connection between two body parts.
already.
• Used for tumors or as an adjunct therapy if metastasis has
occurred.
• Cisplatin (Paclitaxel) – the common drug for chemotherapy.

PICTURE MNEMONIC OF COMMON CHEMOTHERAPEUTIC

DRUGS AND THEIR TOXIC EFFECTS
1. Methotrexate – stomatitis
2. Bleomycin – pulmonary fibrosis
3. Cisplatin/Carboplatin – ototoxicity & nephrotoxicity
4. Cyclophosphamide – hemorrhagic cystitis
5. Doxorubicin – cardiac toxicity
6. 5-FU (Fluorouracil) & 6-MP (Mercaptopurine) -
myelosuppression
7. Vincristine – peripheral neuropathy

NURSING INTERVENTIONS
FEAR: Many people believe that cancer means death. However, this is
no longer true especially with early diagnosis.
• Explain that 92% of all women with cervical cancer survive for 5
years or more and that the earlier the cancer is detected, the better
the prognosis.
• Allow adequate time for the woman and her family to express
their concerns and ask questions. Unexpressed feelings and
fears and lack of understanding may cause the woman to view the
situation as worse than it already is
• Refer to cancer counsellor or support groups for additional
information. Cancer survivors and people in the hospital provide
proof that people can survive the diagnosis and treatment of
cancer and even lead normal productive lives.

IMPAIRED SKIN INTEGRITY: Because of the surgery that was

performed, it interrupts the integrity of the skin surface and it will
provide a potential portal for the invasion of your microorganisms such
as bacteria and viruses. Also, radiation can actually cause impaired
skin integrity because it can cause an inflammatory response in the
skin and mucous membranes within the field of radiation.
• Provide health education on wound and skin care, particularly
if pelvic exenteration is performed. Irrigations with saline or
other prescribed solutions can be performed at intervals. We
should perform this because the open and damaged tissue will
increase the risk of infection. With this one, it requires meticulous
skin care and wound care to prevent further tissue destruction.
• If appropriate, provide education on stoma care and care for
the skin surrounding the stoma. This is specific for clients who
underwent pelvic exenteration because after the procedure they
are going to have a stoma.
• Apply non-oil-based lotions to skin to help minimize itching and
maintain integrity.
• Educate the woman about the importance of the markings
used to localize the radiation beam to the target area and not
to remove them. These markings are used in future radiation
treatments.

4
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 5
COLORECTAL CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 29 2021
TRANSCRIBED BY ZARAHTESS RUBIO

COLORECTAL CANCER CLINICAL MANIFESTATIONS OF COLORECTAL CANCER

• Tumors of the colon and rectum are relatively common; the • The symptoms of colorectal cancer will depend largely on the
colorectal area (the colon and rectum combined) is the third most location of the tumor, the stage of the disease, and the function of
common site of new cancer cases in the United States. the affected intestinal segment.
• Colorectal cancers (CRCs) are currently the third leading site of
malignancy in the Philippines. The incidence of CRC has 1. The change in bowel habits – most common presenting symptom
escalated from 5,787 in 2010 to 9,625 in 2015. Historical data 2. Passage of blood in or on the stools – second most common
estimate 3- and 5-year survival for colon cancer to be 38.1% and symptoms and are actually red flags that would warrant a medical
33.9% and that of rectal cancer 31.3% and 20%, respectively. evaluation.
3. Non-specific symptoms such as unexplained anemia anorexia,
RISK FACTORS OF COLON CANCER and weight loss
1. Cigarette smoking
2. Family history of colon cancer (Lynch syndrome) or polyps (familial CLINICAL MANIFESTATIONS (BY STAGE OF THE DISEASE)
adenomatous polyposis) • Early disease – there will be none or non-specific symptoms
3. High consumption of alcohol (i.e., above 2 drinks daily in men, • More advanced disease – there is going to be abdominal
above 1 drink daily in women) tenderness, palpable abdominal mass, hepatomegaly (enlargement
4. High-fat, high-protein (with high intake of beef) and low-fiber diet of liver), and ascites.
5. History of genital cancer (e.g., endometrial cancer, ovarian cancer)
or breast cancer in women CLINICAL MANIFESTATIONS (BY LOCATION OF THE DISEASE)
6. History of inflammatory bowel disease
7. History of type 2 diabetes
8. Increasing age
9. Male gender
10. Overweight or obesity
11. Previous colon cancer or adenomatous polyps
12. Racial/ethnic background: African-American or Ashkenazi Jewish

PATHOPHYSIOLOGY OF COLORECTAL CANCER

• Ascending colon – there is going to be pain, mass change in bowel

habits, and anemia
• Transverse colon – there is pain, obstruction, change in bowel
habits and anemia
• Descending colon – there is going to be pain, change in bowel
habits, bright red blood in the stools, and obstruction
especially if the tumor has grown big enough
• Rectum – there is going to be blood in the stool, change in bowel
1. Polyps (adenomas) habits, and rectal discomfort
• Polyps actually tissue rolls that are small and flat in shape.
Adenomas are just benign tumors of the epithelial tissues, and DIAGNOSTIC FINDINGS
actually starts as benign.
2. Tumor grows.
3. Cancer invades and penetrates the wall of colon.
4. Cancer gain access to the lymph nodes and spreads to distant
sites.
• Because of angiogenesis, it can also gain access to the
vascular system.
• Through the process of invasion and metastasis, it is going to
start spreading to other distant sites. Since the venous blood
leaving the colon and the rectum will flow through the portal
vein and inferior rectal vein.
• The liver is usually the common site of the metastasis of
colorectal cancer. It can also spread to the other sides, such as
to the lungs, bones, and even brain. 1. Colonoscopy
• Is the only screening test that can also simultaneously remove
precancerous polyps, thus preventing colorectal cancer.
• It is a direct visualization procedure. Basically it is like a
camera that is being inserted via rectum (Based on the picture
above). There is a camera at the tip of flexible tube and there
is a scope that can be viewed via monitor.

1
2. Tumor biopsy 2. Abdominoperineal resection with permanent sigmoid
• For histology study colostomy
3. BCBC
• May or may not reveal anemia. Anemia is a decrease in the
hemoglobin
4. Chemistry panel
• To determine the baseline status
5. Liver function tests
• This is to screen for possible liver metastasis. It is the usual site
of metastasis for colorectal cancer
6. Carcinoembryonic antigen (CEA)
• A tumor marker that is recommended for assessing the
presence of colorectal cancer, as well as its progression or
recurrence
7. Contrast CT scans of the abdomen, pelvis, and chest
• Indication: Rectal carcinoma situated in the distal (lower) one-third
• To screen for the extent of tumor and any metastasis of the rectum
• Removal of the tumor and the portion of the sigmoid and all of the
STAGES OF COLORECTAL CANCER rectum and anal sphincter, also called Miles resection
• Because with this one, the end part of the descending colon is going
to be brought outside, thus, at the end of the surgery, the patient is
going to have a stoma on his abdominal wall and it will be attached
to the colostomy bag, where the patient is now going to defecate
permanently.

3. Colostomy

1. Stage 0 (carcinoma in situ)

• The cancer has not yet grown beyond the mucosal layer
2. Stage 1 • Surgical resections of the bowel may be accompanied by a
• The cancer has grown beyond the mucosa into the submucosa, colostomy for diversion of fecal contents
but there is still no involvement of lymph nodes • Colostomy is an ostomy made in the colon. Ostomy is a surgery that
3. Stage 2 makes a temporary or permanent opening in the skin called stoma
• Which means that the cancer has grown beyond the • It may be created if the bowel is obstructed by the tumor, as a
submucosa into the muscle layer. There is still no involvement temporary measure to promote healing of anastomosis or as a
of lymph nodes and no metastasis involved permanent means of fecal evacuation when the distal colon and
4. Stage 3 rectum are removed. A colostomy can be done in different parts of
• With stage 3 colorectal cancer, there is already a lymph node the colon. It can be done in cecum colon, ascending colon,
involvement. However, there is still no metastasis transverse colon, descending colon, and sigmoid colon. It will
5. Stage 4 depend as to where the location of the tumor is.
• There is lymph node involvement and there is already a
metastasis to the other organs. A. Sigmoid Colostomy

MEDICAL MANAGEMENT OF COLORECTAL CANCER

• The treatment for colorectal cancer will depend on the stage of this
of the disease and will consist of surgery to remove the tumor,
supportive therapy, and adjuvant therapy.

SURGICAL MANAGEMENT OF COLORECTAL CANCER

• Surgery is the main stay of treatment for colorectal cancer, it may
be curative and it can also be palliative.

1. Segmental resection with anastomosis

• Removal of the tumor and portions of the bowel on either side
of the growth, as well as the blood vessels and lymphatic nodes • Part of the colon is going to be brought outside that is why at the
• Resection means the removal of that particular part of the end of the, procedure the client is going to have a colostomy
intestine, anastomosis is the surgical connection between two bag, you have to expect that when you receive the patient from
structures. In the case of large intestines, this means that the the OR, you are going to see colostomy bag.
two remaining ends are going to be sewn together.
• Whichever part the tumor is located, that that part has to be
really removed, as well as the blood vessels and the lymphatic
nodes.

2
B. Hartman Procedure NURSING MANAGEMENT OF COLORECTAL CANCER
PROVIDING THE PRE-OPERATIVE CARE
1. Maintaining Optimal Nutrition
• The physical preparation for the surgery will involve building the
stamina of the patient prior to the procedure
• A diet high in calories, protein, carbohydrates, and low in residue
for several days before the surgery
• A full or clear liquid diet may be prescribed for 24 to 48 hours
before surgery.
• If patient is hospitalized in the days preceding the surgery, a
parental nutrition may be required to actually replace the
depleted nutrients, vitamins, and minerals. In some instances,
parental nutrition is given at home before surgery.
• A common temporary colostomy procedure. The distal portion of 2. Preventing Infection
the colon is left in place and it is being sewn closure. This one is • Bowel Cleansing evening before and morning of surgery
actually done to allow the bowel to rest. • Oral antibiotics prior to surgery as prophylaxis against infection.
We can give kanamycin (Kantrex), ciprofloxacin (Cipro),
ADDITIONAL INFORMATION neomycin (Mycifradin), metronidazole, and cephalexin
(Keflex).
3. Maintaining The Fluid Volume Balance
• If the patient is vomiting and the patient could be vomiting maybe
because of an obstruction in the colon that could cause
vomiting.
• Measure and record the I&O
• Oral and fluids restrictions to prevent vomiting, this is because if
you give fluids that would promote more vomiting
• Antiemetics
• NGT tube to drain the accumulated fluids and to prevent
abdominal distension. This intervention is also used in cases of
intestinal obstruction
• Observe for signs of hypovolemia; assess hydration status; and
4. Radiation Therapy report decreased skin turgor, dry mucous membranes, and
concentrated urine
4. Providing Emotional Support
• Assess the patient's anxiety level and coping mechanisms
• Suggest methods for reducing anxiety, such as deep-breathing
exercises and visualizing a successful recovery.

PROVIDING THE POST-OPERATIVE CARE

1. Maintaining Optimal Nutrition
• Health teachings on a healthy diet
• Individualized diet plan in consultation with the doctor and the
nutritionist as well
2. Providing Wound Care
• Small rectal cancers may be treated with intracavitary, external or • Assess for signs of hemorrhage, especially during the first 24
implementation radiation. In other words, it can be done by a tally hours after the procedure
therapy or via weekly therapy. • Splint the abdominal incision during coughing and deep
• Radiation therapy is not the primary treatment for colon cancer, breathing, this is to lessen the tension on the edges of the
this is just an adjunctive treatment and it is used with surgical incision
resection for treating rectal tumor. • Monitor for signs of infection, such as fever, increase in
• This has to be done because the rectal cancer has a high rate of a respiratory rate, and pulse rate as these are indicative of an
regional recurrence following a surgical resection, especially if the infectious process
tumor has invaded tissues outside the bowel wall or regional lymph • For perineal route removal of malignancy, observed for perineal
nodes. wound for bleeding. This wound may also contain a drain or a
• Pre- or postoperative radiation therapy reduces the recurrence of packing that is removed gradually and bits of tissue may slough
pelvic tumors. off for a week.
• Radiation is therapy is also used preoperatively to shrink the large • To hasten sloughing of tissue: Sitz bath or mechanical irrigation
rectal tumors enough to permit their surgical removal. 3. Monitoring and Managing Potential Complication
• Frequently assess the abdomen including the bowel sounds and
5. Chemotherapy abdominal girth to detect bowel obstruction
• Chemotherapeutical agents, such as intravenous fluorouracil (5- • Report rectal bleeding, any abrupt change in abdominal pain in
FU) and folinic acid (leucovorin), are also used postoperatively as abdominal pain, elevated WBC count, and symptoms of shock.
adjunctive therapy for colorectal cancer.
• When combined with radiation therapy, chemotherapy reduces the NURSING CARE OF THE PERSON WITH A COLOSTOMY
rate of tumor recurrence and prolongs survival in people with stage • Assess the location of the stoma and the type of colostomy
2 and stage 3 rectal tumor. performed. Stoma location is an indicator of the section of bowel in
• The benefit for your colon cancers is less clear, but chemotherapy which it is located and a predictor of the type of fecal drainage to
may be used to reduce its spread to the liver and prevent expect.
recurrence. • Assess stoma appearance and surrounding skin condition
frequently. Assessment of stoma and skin condition is particularly
important in the early postoperative period, when complications are
most likely to occur and are most treatable.
• Position a collection bag or drainable pouch over the stoma. Initial
drainage may contain more mucus and serosanguineous fluid than
3
 fecal material. As the bowel resumes function, drainage becomes FOODS THICKENING STOOLS
fecal in nature. The consistency of drainage depends on the stoma 1. Apple sauce
location in the bowel. 2. Bananas
• If ordered, irrigate the colostomy, instilling water into the colon 3. Bread
similar to an enema procedure. The water stimulates the colon to 4. Cheese
empty. 5. Pasta
• When colostomy irrigation is ordered for a person with a double- 6. Pretzels
barrel or loop colostomy, irrigate the proximal stoma. Digital 7. Rice
assessment of the bowel direction from the stoma can assist in 8. Smooth peanut paste
determining the proximal stoma. The distal bowel carries no fecal 9. Tapioca
contents and does not need irrigation. It may be irrigated for 10. Yoghurt
cleansing just prior to re-anastomosis.
• Empty a drainable pouch or replace the colostomy bag as needed FOODS LOOSENING STOOLS
or when it is no more than one-third full. If the pouch is allowed to 1. Chocolate
overfill, its weight may impair the seal, causing leakage. 2. Dried beans
• Provide stomal and skin care for a person with a colostomy as for a 3. Fried foods
person with an ileostomy. Good skin and stoma care is important to 4. Greasy foods
maintain skin integrity and function as the first line of defense 5. Highly spiced foods
against infection. 6. Leafy green vegetables
• Use caulking agents, such as stomahesive or karaya paste and a 7. Raw fruits and juices
skin barrier wafer, as needed to maintain a secure ostomy pouch. 8. Raw vegetables
This is particularly important for a person with a loop colostomy. The
main challenge for a person with a transverse loop colostomy is to FOODS COLORING STOOLS
maintain a secure ostomy pouch over the plastic bridge. 1. Beetroot
• If the pouch does not incorporate an air vent, a small needle hole 2. Red and green jelly
high on the colostomy pouch allows flatus to escape. This hole may
be closed with a Band-Aid, and opened when the person is in the
bathroom, for odor control. Ostomy bags may balloon' out,
disrupting the skin seal, if excess gas collects.

HEALTH EDUCATION FOR THE PERSON AND FAMILY

• Prior to discharge, provide written, verbal and psychomotor
instruction on colostomy care, pouch management, skin care and
irrigation to the person. Whether the colostomy is temporary or
permanent, the person will be responsible for its management.
Good understanding of procedures and care enhances the ability to
provide selfcare, as well as self-esteem and control.
• Allow ample time for the person (and their family, if necessary) to
practice changing the pouch, either on the person or a model.
Practice of psychomotor skills improves learning and confidence.
• If an abdominoperineal resection has been performed, emphasize
the importance of using no rectal suppositories, rectal temperatures
or enemas. Suggest the person carry medical identification or a
Medic Alert® tag or bracelet. These measures are important to
prevent tissue trauma when the rectum has been removed.
• The diet for a person with a colostomy is individualized and may
require no alteration from that consumed preoperatively. Dietary
teaching should, however, include information on foods causing
stool odor and gas, and foods that thicken or loosen stools. Foods
causing these effects on ostomy output are listed below.

FOODS INCREASING STOOL ODOR

1. Asparagus
2. Beans
3. Cabbage
4. Eggs
5. Fish
6. Garlic
7. Onions
8. Some spices

FOODS INCREASING INTESTINAL GAS

1. Beer
2. Broccoli
3. Brussels sprouts
4. Cabbage
5. Carbonated drinks
6. Cauliflower
7. Corn
8. Cucumbers
9. Dairy products
10. Dried beans
11. Peas
12. Radishes
13. Spinach
4
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 6
GASTRIC CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 29 2021
TRANSCRIBED BY AYESSA VILLAMOR & KRISTA BALLA

GASTRIC CANCER DIAGNOSTIC STUDIES FOR GASTRIC CANCER

• Gastric remains to be most common and most deadly cancers 1. Esophagogastroduodenoscopy for biopsy and cytologic
worldwide especially among the older male population and based washings - it is the diagnostic study of choice because it directly
on the GLOBOCAN 2018 data, stomach cancer is the fifth most studies tissues
common neoplasm and is also the third deadliest cancer with an 2. Barium x-ray examination of the upper GI tract - a form of
estimated 783,000 deaths in 2018. radiographic examination and the client will have to drink or to ingest
barium that could help the visibility of your gastrointestinal. It is also
RISK FACTORS OF GASTRIC CANCER used to diagnose abnormalities of the GI tract such as tumors,
1. H. pylori infection - the stomach cancer begins with a non-specific ulcers, and strictures etc.
mucosal injury because of this infection of your h. pylori infection. 3. Endoscopic ultrasound - to assess tumor depth and any lymph
2. Autoimmune-related inflammation node involvement
3. Repeated exposure to irritants such as NSAIDs 4. Computed tomography (CT) scanning - to assess for surgical
4. Lymphoma of the stomach resectability of the tumor before surgery is scheduled. It is also
5. Genetic predisposition - only about 10% of stomach cancer have valuable in staging gastric cancer
an inherited component 5. CBC - may be used to evaluate for the presence of anemia
6. Chronic gastritis 6. Tumor markers (carcinoembryonic antigen (CEA),
7. Pernicious anemia - it is caused by a deficiency of your vitamin carbohydrate antigen (CA 19-9, and CA 50) - are monitored to
b12 determine the effectiveness of treatment.
8. Gastric polyps- abnormal tissue growth
9. Carcinogenic factors in the diet (such as smoked foods and MEDICAL MANAGEMENT OF GASTRIC CANCER
nitrates)
10. Achlorhydria - lack of hydrochloric acid in the stomach SURGERY
11. Smoking • The surgical aim is to remove as much of the stomach as required
12. Obesity to remove the tumor and a margin of normal tissue.
13. Occupation that involves exposure to certain chemicals such • The location and extent of the lesion, the patient’s physical
as dust, asbestos, solvents and pesticides condition, and the health care provider’s preference determine the
14. Diet poor in fruit and vegetables and lacking antioxidant specific surgery used (e.g., open versus laparoscopic)
mechanism
1. Billroth I or II procedure
CLINICAL MANIFESTATIONS OF GASTRIC CANCER • Billroth I -
• Few symptoms are associated with gastric cancer. Unfortunately, gastroduodenostomy
the disease is often advanced and metastases are usually present • Billroth II -
at the time of diagnosis gastrojejunostomy
• Early symptoms - Vague, including feelings of early satiety, • Lesions in the antrum
anorexia, indigestion, and possible vomiting, ulcer-like pain. or pyloric region
• Disease progress - Anemia. Weight loss, cachexia, presence of
abdominal mass, GI bleeding Sister Mary Joseph’s nodules. (Show
picture below)
• Signs of metastases - Supraclavicular lymph nodes that are hard
and enlarged and Ascites (poor prognostic sign)

2. Total gastrectomy
• Removal of the entire
stomach
• Done for diffuse cancer that
is spread throughout the
gastric mucosa but limited
to the stomach
• Surgeon constructs an
anastomosis from
esophagus to the
• Sister Mary Joseph’s nodules duodenum or jejenum
- It was named after Sister Mary Joseph who is a surgical assistant
to Dr. William J. Mayo who was the one who noted the association
between the presence of an umbilical neutral. Basically, it’s an
umbilical nodule and it is associated with an intra-abdominal
malignancy, so this is one of the symptoms of gastric cancer.

1
 A COMPLICATION OF TOTAL GASTRECTOMY: TARGETED THERAPY
DUMPING SYNDROME • More specific
1. Trastuzumab (Herceptin)
• About 20% of patients with stomach cancer have too much
HER-2 on the surface of the cancer cells
• Trastuzumab targets te HER-2 protein and kills the cancer
cells
2. Ramucirumab (Cyramza)
• Ramucirumab binds to the receptor for VEGF and prevents
VEGF from binding to the receptor, thus preventing the growth
and spread of cancer
• This receptor is responsible for promoting the growth of new
blood vessels. In other words, this has something to do with
angiogenesis so we don’t want angiogenesis to happen so we
prevent the EGF from binding to the receptor. Thus,
preventing the growth and spread of cancer

PROGNOSIS OF GASTRIC CANCER

1. At this point, there is a rapid movement of hypertonic chyme into • Because gastric cancer is generally advanced by the time of
small intestine diagnosis, the prognosis is poor – metastasis is the killer in
2. Fluid IS drawn into the bowel by osmosis cancer and if you caught the cancer at the time where it is already
3. Effects include: metastatic then of course that the prognosis is going to be poor
a. Decreased blood volume - tachycardia, orthostatic hypotension, • The 5-year survival rate of all people treated for gastric
dizziness, flushing, diaphoresis carcinoma is 20%
b. Intestinal Dilation - increased peristalsis
c. Nausea and vomiting, epigastric pain, abdominal cramping, NURSING MANAGEMENT OF GASTRIC CANCER
borborgymus and diarrhea. REDUCING ANXIETY
• It is expected for a disease as fatal as this, there’s going to be a lot
NURSING MANAGEMENT FOR DUMPING SYNDROME of anxiety
• The principle here is to slow down the movement of food across the • Educate the patient about any procedures and treatments
GI tract. • Provide a relaxed, nonthreatening atmosphere is provided so the
1. Small frequent feedings patient can express fears, concerns, and possible anger
2. Liquids and solids are taken at a separate time – helps lower the • Offer reassurance and supporting positive coping measures –
movement encourage family presence especially if they are really the support
3. Increased proteins and fats in the diet, low carbohydrates – more of the client and offer reassurance and support positive coping
proteins and fat less carbohydrates measures
4. Recumbent position / semi – recumbent position 30 to 60 minutes
after meals PROMOTING OPTIMAL NUTRITION
5. Anticholinergics, sedatives and antispasmodics • Eat small, frequent portions of nonirritating foods to decrease gastric
irritation
OTHER COMPLICATIONS OF GASTRIC CANCER • Injection of Vitamin B12 will be required for life
1. Anemia • Individualize dietary interventions
a. Vitamin B12 deficiency • Monitor the IV therapy and nutritional status and record intake,
- The stomach will produce intrinsic factor and the intrinsic output and daily weights
factor is actually required for the absorption of Vitamin B12 • Assess for signs of dehydration (thirst, dry mucous membrane,
and of course Vitamin B12 can lead to anemia poor skin turgor, bradycardia, decreased urine output)
b. Iron deficiency
• Review the results of daily laboratory studies to note any metabolic
- Iron is absorbed primarily in your duodenum and proximal
abnormalities
jejunum. Therefore, a rapid gastric emptying may interfere
with the adequate absorption of iron.
RELIEVING PAIN
2. Folic Acid Deficiency
• Pain assessment
3. Decreased absorption of calcium and Vitamin D
4. Weight Loss – poor absorption of nutrients combined with the • Postoperative Pain: continuous IV infusion of an opioid or a patient-
controlled analgesia (PCA)
inability to eat large meals will put the person at risk
• Nonpharmacologic methods for pain relief, such as position
changes, imagery, distraction, relaxation exercises (using relaxation
CHEMOTHERAPY
audiotapes), backrubs, massage and periods of rest and relaxation.
1. Chemotherapeutic Drugs - number of chemotherapeutic drugs
can be used to treat stomach cancers PROVIDING PSYCHOLOGICAL SUPPORT
• Fluorauracil, capecitabine (Xeloda), carboplatin, cisplatin, • Helps the patient express fears, concerns and grief about the
docetaxel (Taxotere), epirubicin (Ellence), irinotecan diagnosis
(Camptosar), oxaliplatin (Eloxatin), and paclitaxel
• Answer the patient’s questions honestly and encourages the patient
2. Combination Therapy – preferred as the drugs will affect different
to participate in treatment decisions
phases of the cell cycle. Therefore, it’s more effective
• Offer emotional support and involves family members and
• Include ECF (epirubicin, cisplatin, fluorouracil) and docetaxel,
significant others whenever possible
irinotecan, oxaliplatin or cisplatin with fluorouracil or
• The services of clergy, psychiatric clinical nurse specialists,
capecitabine
psychologists, social workers and psychiatrists are made available
CHEMOTHERAPY
• Projects an empathetic attitude and spend time with the patient
RADIATION THERAPY
INDICATIONS:
• Used together with chemotherapy to reduce the recurrence of
tumor
• Used as a palliative measure to decrease tumor mass and provide
temporary relief of obstruction

2
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 7
OVARIAN CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 29 2021
TRANSCRIBED BY TOM CUENCA

OVERVIEW 3. Epithelial Ovarian Cancer

• Ovarian cancer is the 7th most common cancer in women worldwide. • Starts in the egg cells. These tumors are very rare, making up
It is diagnosed annually in nearly a quarter of a million women less than 2% of ovarian cancers. They occur in younger women
globally and is responsible for 140,000 deaths each year and girls.
• In the Philippines, it is the fifth most common cancer among Filipino
women (DOH) RISK FACTORS OF OVARIAN CANCER
• The exact cause of ovarian cancer is not known however, the
ANATOMY AND PHYSIOLOGY OF THE OVARY major risk factors include:
• Ovarian cancer is a group of diseases that originates in the ovaries, 1. Family history (1 or more first-degree relatives with ovarian
or in the related areas of the fallopian tubes and the peritoneum cancer)
• Women have two ovaries that are located in the pelvis, one on each 2. Family history of breast or colon cancer
side of the uterus 3. Personal history of breast or colon cancer and HNPCC
• The ovaries make female hormones and produce eggs (oocytes) for (hereditary non-polyposis colorectal cancer, a hereditary
reproduction cancer susceptibility disorder associated with a high risk for
carcinoma of the colon and certain colonic cancers)
• Women have two fallopian tubes that are a pair of long, slender
4. Mutations of the BRCA genes (BRCA genes are tumor
tubes on each side of the
suppressor genes that inhibit tumor growth when functioning
uterus
normally)
• Eggs pass from the ovaries
5. Nulliparity
through the fallopian tubes
6. Increasing age
to the uterus
7. High-fat diet
• The ovaries have three 8. Early menarche and late menopause
main cell types.
9. Hormone replacement therapy (HRT)
a. The surface cells
10. Use of infertility drugs
(epithelial cells) cover the
surface of the ovary
PROTECTIVE FACTORS OF OVARIAN CANCER
b. The germ cells produces
the eggs or ova 1. Breastfeeding
c. Stroma cells are 2. Multiple pregnancies
structures that hold the 3. Oral contraceptive [OCP] use (more than 5 years)
structure of the ovary 4. Early age at first birth
together and make
hormones such as the STAGING OF OVARIAN CANCER
estrogen and progesterone.

PATHOPHYSIOLOGY OF OVARIAN CANCER

• The types of ovarian cancer are grouped by the kind of cell where
they start. If they start in the epithelial cells, then they are called it is
called as epithelial ovarian cancer

STAGE 1
• Cancer is found in one or both ovaries
STAGE 2
• Cancerous cells have spread from the ovaries to other parts of the
pelvis, such as the fallopian tubes or uterus
STAGE 3
• Cancerous cells have spread outside the pelvis to the nearby lymph
nodes, diaphragm, intestines or liver.
STAGE 4
• The cancer has spread (more distant) beyond the abdomen, such
as to the lungs or spleen
1. Epithelial Ovarian Cancer
• It is a tumor that starts on the outside of the ovary. The majority
of cancer-causing ovarian tumors are epithelial
• Make up about 90% of ovarian cancers

2. Stromal Cancer
• Starts from ovarian cells that make hormones. Doctors can
typically diagnose these early. They make up about 1% of
ovarian cancer

1
 COMPLICATIONS OF OVARIAN CANCER CHEMOTHERAPY
Complications of Assessments Treatment • The chemotherapy agents most commonly used are taxanes
Advanced Ovarian (paclitaxel or docetaxel) and platinum agents (carboplatin and
Cancer cisplatin)
Ascites Abdominal distension Paracentesis
(accumulation of Shiny abdominal skin (removing fluid from TARGETED THERAPY
fluid in the Dullness on the abdomen) • Targeted therapy used to treat advanced ovarian cancer includes
abdominal cavity; a percussion of
bevacizumab (Avastin), rucaparib (Rubraca), and Olaparib
form of third dependent areas
(Lynparza). Rucaparib and Olaparib are poly ADP-
spacing) Dyspnea, constipation
and abdominal pain
robosepolymerase (PARP) inhibitors which block enzymes
Abdominal pain Nasogastric tube involved in repairing damaged DNA
Intestinal
obstruction Projectile vomiting insertion, NBM
Constipation (nothing by mouth) NURSING MANAGEMENT FOR HYSTERECTOMY
Hyperactive bowel 1. Relieve anxiety
sounds 2. Relieve pain
Deep venous Leg edema Anticoagulants 3. Improving body image (post-hysterectomy)
thrombosis Leg pain 4. Monitoring and managing potential complications
Redness, warmth
Lymphedema (leg) Edema of leg Skin care, range of RELIEVING ANXIETY
Decreased range of motion (ROM) • Determine what the experience means to the patient and
motion exercises, massage encourages her to verbalize her concerns
Tight, shiny skin on or physical therapy,
• Give explanations about physical preparations and procedures that
leg compression
bandaging are performed
• Patient education addresses the outcomes of surgery, possible
feelings of loss, and options for management of any symptoms that
CLINICAL MANIFESTATIONS OF OVARIAN CANCER
occur
EARLY STAGE
• In the early stage, you will not be suspicious because the ovarian IMPROVING BODY IMAGE (POST-HYSTERECTOMY)
cancer generally causes no warning signs or symptoms. When
• Reassure the patient that she will still have a vagina and that she
symptoms do develop, they are often vague and mild. The can experience sexual activity after temporary postoperative
symptoms include: abstinence while tissues heal
1. Pelvic or abdominal pain
• Exhibit interest, concern and willingness to listen to the patient’s fear
2. Bloating
which will help the patient progress through the surgical experience
3. Urinary urgency or frequency
4. Feeling full quickly
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
5. Abnormal vaginal bleeding (if tumor erodes the vaginal wall)
1. Hemorrhage
• Count the perineal pads used or check the incision site, assess
LATE STAGE
the extent of saturation with blood and monitor vital signs
• The clinical manifestations include:
• Abdominal dressings are monitored for drainage if an abdominal
1. Abdominal enlargement with ascites
surgical approach has been used
2. Unexplained weight loss or gain
3. Menstrual changes • In preparation for hospital discharge, the nurse gives prescribed
guidelines for activity restrictions to promote healing and to
prevent postoperative bleeding
DIAGNOSTIC TEST AND FINDINGS OF OVARIAN CANCER
2. Venous Thromboembolism: caused by the positioning during
1. CA125 test surgery, post-operative edema, and decreased activity
• It is positive in 80% of women with epithelial ovarian cancer • Antiembolism stockings are applied
• It is also used to monitor the course of the disease and • Encourage and assist patient to change positions frequently,
response of treatment although pressure under the knees is avoided and to exercise
2. Abdominal or transvaginal ultrasound her legs and feet while in bed
• Detects ovarian masses • Early ambulation
3. Exploratory laparotomy
• The nurse also assesses for DVT (leg pain, redness, warmth,
• May be used to establish the diagnosis and stage the disease edema) and PE (chest pain, tachycardia, and dyspnea)
• Instruct patient to avoid prolonged sitting in a chair with pressure
MEDICAL MANAGEMENT OF OVARIAN CANCER at the knees, sitting with crossed legs, and inactivity
PREVENTIVE MEASURES 3. Urinary (Bladder) Dysfunction: common problem following
• Options for women at high risk based on family and health history hysterectomy and can be caused by the damage to the nerves controlling
• Prophylactic removal of the ovaries and fallopian tubes, however it urination
does not completely eliminate the risk for ovarian cancer • After catheter is removed, urinary output is monitored;
• Oral contraceptive drugs additionally, the abdomen is assessed for distention
• If the patient does not void within a prescribed time, measures
SURGERY are initiated to encourage voiding (e.g., assisting the patient to
• Total abdominal hysterectomy and the bathroom, pouring warm water over the perineum). If the
bilateral salpingo-oophorectomy patient cannot void, catheterization may be necessary
(TAHBSO) with removal of the • On rare occasions, the patient may be discharged home with the
omentum and as much of the tumor as catheter in place and is instructed in its management
possible (e.g., tumor debulking)
• The initial treatment for all stages of
ovarian cancer

RADIATION THERAPY
• Radiation therapy using external-beam or intracavitary implants
(brachytherapy) is performed for palliative purposes only and is
directed at shrinking the tumor at selected sites

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 MEDICAL-SURGICAL NURSING┃SEMIFINALS┃TRANS 8
THYROID CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃NOV 29 2021
TRANSCRIBED BY CAMILLE BUTAO AND CHRISTINE SUNGA

THYROID CANCER RISK FACTORS

• Thyroid cancer is the most common type of cancer of the endocrine • Woman in 40s to 50s. It is unclear as to why this happens but
system. thyroid cancer does occur about three times more often in women
• It is estimated that there are 62, 450 new cases of thyroid cancer than in men.
that are diagnosed annually • Head and neck therapy during childhood. The risk will depend
• The incidence of thyroid cancer has increased significantly in the on how much radiation is given and the age of the child. In general,
past 25 years the risk increases with larger doses and with younger age at
treatment.
ANATOMY AND PHYSIOLOGY • Radioactive fallout exposure
• Personal or family history of goiter. If a person has a first degree
relative with thyroid cancer, he/she can also have that risk. If a
person has a history of goiter also, that is considered a risk.
• Being overweight / Obesity. People who are overweight or obese
have a higher risk of developing thyroid cancer than those who are
not. The risk appears to go up as the body mass index increases.
• Low iodine in the diet. The follicular thyroid cancer which is one
type of thyroid cancer are actually more common in areas of the
world where the people’s diet is actually low in iodine. On the other
hand, if a person’s diet is high in iodine, it may also increase the risk
of another type of thyroid cancer which is the papillary thyroid
cancer.

THYROID NODULES AND CANCER

• A thyroid nodule (growth in the thyroid gland) may be benign or
malignant (thyroid cancer). When we say malignant, this means the
cancerous type of growth.
• With the benign nodules, it accounts for 95% of the cases and they
are usually not dangerous, but they can cause tracheal
compression if they become too large. Unless they can cause
tracheal compression that has the potential of obstructing the
airway, it can become dangerous.
• Thyroid cancer accounts for 5% of the cases of thyroid nodules,
THYROID GLAND however, it is the most common type of cancer of the endocrine
• The thyroid gland is butterfly in shape and it is located just below system.
the Adam's apple. If you do a palpation on the neck, this can be
palpated during physical exam. TYPES OF THYROID CANCER
• Thyroid gland has two lobes that function as one unit. 1. Papillary Thyroid Cancer
• One important function of the thyroid gland is that it produces 2. Follicular Thyroid Cancer
3. Medullary Thyroid Cancer
the hormone thyroxine (T4) and triiodothyroxine (T3), these
4. Anaplastic Thyroid Cancer
two hormones are actually collectively called thyroid hormones.
• Basically, thyroid hormones can control the body’s PAPILLARY THYROID CANCER
metabolism, heartbeat, temperature, mood, and other
• It is the most common type of cancer which accounts for about 70%
important processes, and it can reach out to nearly every single
to 80% of all thyroid cancers.
cell in the body.
• This tends to grow slowly.
• Thyroid gland also produces calcitonin, this calcitonin • It initially spreads to lymph nodes in the neck.
maintains the blood calcium level by inhibiting the release
of calcium from the bone. FOLLICULAR THYROID CANCER
• Makes up about 15% of all thyroid cancers.
PARATHYROID GLAND
• This tends to occur in older patients.
• Parathyroid glands are located at the or embedded on the
• First metastasizes into the cervical lymph nodes and then spreads
posterior surface of the thyroid. Because one of the treatment to the neck, lungs, and bones.
of the thyroid cancer is performing surgery or removing the • The follicular and papillary thyroid cancer are referred to as well
thyroid gland. This could also mean that the parathyroid glands differentiated thyroid cancer.
can also be affected, that is why it is important to also know the
function of this gland. MEDULLARY THYROID CANCER
• One of the important functions of the parathyroid gland is to • Accounts for up to 10% of all thyroid cancer. This more likely to
produce a parathyroid hormone. occur in families and be associated with other endocrine problems.
What this parathyroid hormone do is that: • This can be diagnosed by genetic testing for a proto-oncogene
o It helps regulate blood calcium balance by adjusting the rate called RET.
at which calcium and magnesium ions are removed from • Medullary thyroid cancer is a type of multiple endocrine
the urine. neoplasia. Which means that this type of cancer is often poorly
o It increases movement of phosphate ions from the blood to differentiated.
urine for excretion. • This is associated with early metastasis.
1
 ANAPLASTIC THYROID CANCER THYROID FUNCTION TESTS (TSH, T3, T4)
• Occurs in less than 2% of patients with thyroid cancer.
• It is the most advanced and aggressive thyroid cancer.
• With this one, the patient is likely to respond to treatment and has a
poor prognosis.

CLINICAL MANIFESTATIONS
• Painless, palpable nodule or nodules in an enlarged thyroid
gland. Primary manifestation of thyroid cancer. Upon inspection,
you can actually already see that there is enlargement, or upon
palpation, you can feel that there is an enlargement.
• Firm, palpable, cervical masses. Suggests lymph node
metastasis.
• Difficulty swallowing or breathing. This is because of the tumor
growth invading the trachea or esophagus.
• Hemoptysis and airway obstruction. May occur if the trachea is
involved.
• A serologic testing.
• The TSH is released by the pituitary gland, testing this may be used
DIAGNOSTIC FINDINGS to check the overall activity of the thyroid gland.
• The levels of TSH may be high if the thyroid is not making enough
THYROID SCAN hormones. However, in the case of thyroid cancer, TSH level is
usually normal.
• Other tests are the T3 and T4 which are hormones that are released
by the thyroid gland and it may be helpful in evaluating thyroid
nodules and masses; however, results are rarely conclusive. This
test can also guide a physician on which imaging test is he or she
going to use. Like, should he use an ultrasound or radium iodine
scans which is going to guide the next testing that is going to be
involved.

SERUM CALCITONIN

• Shows whether the nodules on the thyroid are “hot” or “cold”.

• “Hot” tumors take up radioactive iodine. They are almost always
benign.
• If the nodule does not take up the radioactive iodine, it appears as
“cold” and has a higher risk for being cancer.
• Helpful in evaluating thyroid nodules and masses.

FINE NEEDLE BIOPSY

• Which are associated with medullary thyroid cancer.
• Serum thyroglobulin which is high in papillary and follicular
cancer.

MEDICAL MANAGEMENT
• Surgery. Or surgical removal of thyroid carcinoma is the treatment
of choice for thyroid cancer. The type of surgery that the doctor will
perform will depend on the location and also the spread of the tumor
involved.
The doctor can perform:
o Thyroid Lobectomy which is the removal of one lobe of
the thyroid gland.
o Subtotal Thyroidectomy (based from the image above)
only a portion of one lobe has remained after the surgery.
o Total Thyroidectomy or the removal of all thyroid gland.
Both lobes are already removed.
o The doctor will make efforts to spare parathyroid tissue to
• This is done to differentiate cancerous thyroid nodules from reduce the risk of postoperative hypocalcemia and tetany.
noncancerous nodules and to stage the cancer if detected. The parathyroid tissue is located or embedded at the back
• This procedure is safe and usually requires only a local anesthetic portion of the thyroid gland. It is important to spare them
agent. because it can actually put the patient at risk for
hypocalcemia and tetany.
LARGE-BORE NEEDLE BIOPSY o The parathyroid glands will release parathyroid hormones,
• Second type of biopsy. and these hormones are responsible for the regulation of
• This may be used when the results of the standard biopsy are calcium
inconclusive or with rapidly growing tumors.
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 ABLATION PROCEDURE WITH RADIOACTIVE IODINE supplementation is adequate and to note whether calcium balance
• This is the destroying of your tissue or cells. is maintained.
• Purpose: Ablation procedures are carried out with radioactive
iodine to eradicate residual microscopic disease after surgery. NURSING MANAGEMENT
• Thyroid gland actually uses iodine to produce its hormones, so in • Providing Preoperative Care
other words your thyroid gland is a good concentrator of your iodine • Providing Postoperative Care
and it is safe because radioactive iodine is primarily absorbed by the • Monitoring and Managing Potential Complications
thyroid cells. Thyroid cells are the main cells in the body that can • Promoting Home, Community-Based and Transitional Care
absorb your IUD. In other words, no other cells are going to be
exposed by the radiation. PROVIDING PREOPERATIVE CARE
• This one can be used for thyroid cancers with metastasis. • Diet high in carbohydrates and proteins - it is necessary because
of the increased metabolic activity and the rapid depletion of your
glycogen wheezers.
• Supplementary vitamins, particularly thiamine and ascorbic
acid
• Avoid tea, coffee, cola, and other stimulants
• Facilitate informed consent – the nurse will inform the patient
about the purpose of your pre-op test and if they are performed and
will explain pre-op preparations and what to expect during the
procedure. Information will help the patient and would actually help
reduce the client's anxiety about the surgery.
• Good night’s rest before surgery
• Preoperative teaching on how to support the neck with hands
after surgery - raising the elbows and placing the hands behind the
neck to provide support and reduce strain and tension on the neck
muscles and surgical incision.
• Radioactive iodine is ingested by the patient as a liquid or a capsule
PROVIDING POSTOPERATIVE CARE
form.
• Once in the stomach the iodine will enter the bloodstream and is • Assess the surgical dressings and reinforces as necessary
absorbed by your thyroid cells, attacking the cancer cells. • Watch out for sign of bleeding
• Within two days the radioactive material will pass through the - Like monitoring the pulse, the blood pressure for any indication of
kidneys and excreted from the body. internal bleeding.
• Remember that the urine and all body secretions of the client is - The nurse should be alert if the client would complain that there
going to be radioactive. is a sensation of pressure on or a fullness at the incision side
because that could also be a sign of bleeding.
• In very rare cases when the patient is unable to swallow a feeding
tube can be used to deliver the iodine. • When the patient is in a recumbent position, the nurse
observes the sides and the back of the neck as well as the
anterior dressing for bleeding
THYROID HORMONE THERAPY
• Watch out for: Difficulty in respiration can occur as a result of
• Thyroid hormone therapy in high doses is often prescribed to inhibit edema of the glottis, hematoma formation, or injury to the
pituitary secretion of thyroid stimulating hormone. laryngeal nerve - this complication actually requires that an airway
• Lots of thyroid stimulating hormones are going to be produced by is to be inserted.
your pituitary gland if there is a decrease of your thyroid hormones.
• Tracheostomy set should always be at the bedside
For that to stop there has to be thyroid hormones.
• Pain assessment and pain medications
• The reason why we do this is because many of the thyroid cancers
• Oxygen supplementation - to actually assess the breathing.
are actually TSH dependent. When we say TSH dependent it means
• Support neck when moving and turning the patient - to avoid
that the cancer cells will grow because of your thyroid stimulating
tension on the on the sutures.
hormones that are being released by your pituitary gland.
• Positioning: Semi-fowler, with head elevated and supported by
pillows - this is the most comfortable position according to the book.
CHEMOTHERAPY / TARGETED THERAPY
• IV fluids, water by mouth when nausea subsides and bowel
CHEMOTHERAPY
sounds are present, high caloric diet - to support the nutrition of
• Doxorubicin may be used for advanced disease. the client.
• Advise speaking as little as possible, observe for voice
TARGETED THERAPY
changes - to reduce edema to the vocal cords however if the client
• Tyrosine Kinases: Vandetanib (Caprelsa), Lenvatinib (Lenvima) does speak then we have to take note of the voice changes okay
Sorafenib Tosylate (Nexavar), and Cabozantinib (Cometriq) are because it could indicate possible injury to the recurrent laryngeal
targeted therapies used for metastatic thyroid cancer. nerve which lies just behind the thyroid next to the trachea.
• These drugs inhibit your tyrosine kinesis and these are actually • Provide an overbed table - it is provided for access to frequently
enzymes that are involved in the growth of cancer cells and of used items so that the patient will avoid turning their head and
course the treatment is not enough we have to do follow-up therefore decrease the possibility of adding tension to the suture
checkups. lines.
• Vapor mist inhalations - for the relief of excessive mucus
THYROID HORMONE THERAPY accumulation.
• The first-year evaluation includes clinical examination, TSH and free • Early ambulation
thyroxine and measurement of serum thyroglobulin within six • Health teachings about sutures used - as to whether the sutures
months following the initial treatment, and a routine neck ultrasound are absorbable or not absorbable because the observable sutures
with the first six to twelve months following initial treatment. dissolve within the body and the non-observable ones should be
• Tests used to confirm sites of metastasis if there is clinical evidence removed. The timeline for the removal may vary and the client
of recurrence include radioiodine imaging, CT, MRI, skeletal x-rays, should know when the sutures are going to be removed.
and skeletal radionucleotide imaging.
• Fluorodeoxyglucose (FGDA) PET is useful to establish prognosis if
there is evident evidence of your distant metastasis.
• Free T4, TSH, and serum calcium and phosphorus levels are
monitored to determine whether the thyroid hormone
3
 MONITORING AND MANAGING POTENTIAL COMPLICATIONS
• Hemorrhage
• Hematoma Formation
• Edema of the glottis
• Injury to the laryngeal nerve
• Disturbance in calcium metabolism – Tetany
o This happens because occasionally in thyroid surgery the
parathyroid gland is injured or removed okay thereby
producing this disturbance in metabolism. As the blood
calcium fall, the client will experience hyper irritability of the
nerves, spasms of the hands and feet and muscle twitching.
o This type of tetany can be treated with IV and also this calcium
abnormality is usually temporary after thyroidectomy unless of
course if all of the parathyroid tissues were removed.
• Laryngospasms - this has to be reported right away although this
is kind of rare but it has to be reported right away because it can
cause obstruction of the airway,

4
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 9
CANCER TREATMENT
MRS. APRIL LOVE R. OJA, RN, MAN ┃DEC 06 2021
TRANSCRIBED BY AYESSA VILLAMOR & KRISTA BALLA

(3) PALLIATIVE AND SUPPORTIVE CARE

CANCER TREATMENT • When cure or control of cancer is no longer possible, the focus
1. Cure shifts to supportive care and palliation of symptoms.
2. Control • Examples of supportive care include:
3. Palliative 1. Insertion of a feeding tube to maintain nutrition during head
and neck cancer treatment
FACTORS THAT DETERMINE THE TYPE OF THERAPY • Examples of palliative care include:
1. Tumor histology 1. Tumor debulking to relieve pain or pressure
2. Staging outcomes 2. Laminectomy for the relief of a spinal cord
3. Physiologic status (e.g., presence of co-morbid illnesses) 3. Compression
4. Psychologic status
5. Personal desires NURSING MANAGEMENT
• Assess the patient’s and family’s ability to cope with the
CURE uncertainty of cancer and its treatment and with the changes in
• When cure is the goal, treatment is expected to have the greatest body image and role.
chance of eradicating the cancer. • Coordinate with the health care team to provide support for the
• Curative cancer therapy differs according to the cancer being patient and family.
treated. • Provide information about support groups, such as those specialty
• It may involve local therapies (e.g., surgery or radiation) alone or in cancer organizations.
combination, with or without periods of adjunctive systemic therapy • Discuss with the patient the idea of having a person who has
(e.g., chemotherapy) coped with the same issues come for a visit.
• Coordinate with the physical therapist, occupational therapist, and
CONTROL family members to plan strategies individualized to each patient to
• Control is the goal of treatment for cancers that cannot be regain or maintain optimal function.
completely eradicated but are responsive to anticancer therapies
• Patients may undergo an initial course of treatment followed by CHEMOTHERAPY
maintenance therapy for as long as the disease is responding. • The goal of chemotherapy is to eliminate or reduce the number of
• Patients are monitored closely for early signs and symptoms of cancer cells in the primary and metastatic tumor site(s).
disease recurrence or progression and the cumulative effects of • The effects of the chemotherapy drugs are described in relation to
therapy. the cell cycle.

PALLIATION CATEGORIES
• Palliation is the goal of treatment when the goals are the relief or (1) Cell cycle phase - nonspecific: Have their effect on the cells
control of symptoms and maintaining a satisfactory quality of life. during all phases of the cell cycle. (information inside the box)
• Palliative care and treatment are not mutually exclusive and can (2) Cell cycle phase - specific: Have their greatest effects during
take place concurrently specific phases of the cell cycle (info next to the box)

TREATMENT MODALITIES Cell Cycle (Phase-Specific Agents)

1. Surgery
Antimetabolites Mitotic Inhibitors Topoisomerase
2. Radiation Therapy
Inhibitors
3. Chemotherapy
4. Immunotherapy and Targeted Therapy - Mimic naturally Taxanes - Inhibit
5. Hormonal Therapy occurring - Antimicrotubule topoisomerase that
6. Hematopoietic Stem Cell Therapy substances, thus agents that interfere function to make
interfering with mitosis. Act reversible
with enzyme during the late G2 breaks and repairs
SURGERY
function or phase and mitosis to DNA that
SURGICAL THERAPY DNA synthesis. stabilize allow for flexibility of
(1) PREVENTION Primarily act microtubules, thus DNA in
• Can be used to eliminate or reduce the risk for cancer during 5 phase. inhibiting cell replication
development Purine and division - Etoposide,
• Examples include: pyrimidine are - Docetaxel irinotecan
1. Total colostomy - to prevent colorectal cancer for patients building (Taxotere), (Camptosar)
who have adenomatous familial polyposis blocks of nucleic paclitaxel (Taxol)
2. Prophylactic mastectomy - for patient who have genetic acids
mutations of BRCA1 or BRCA2 and have a strong family needed for DNA Vinca Alkaloids
history of early-onset breast cancer. and RNA - Act in M phase to
synthesis inhibit mitosis
(2) CURE OF CONTROL - Methotrexate - Vincristine,
• When the goal is cure or control, the objective is to remove all or (Trexall), vinblastine
as much resectable tumor as possible while sparing normal tissue. hydroxyurea (
• Examples include: Hydrea),
1. Radical neck dissection, mastectomy, thyroidectomy, capecatibine
nephrectomy, hysterectomy, and/or oophorectomy. (Xeloda)

1
 Cell Cycle Phase (Non-Specific Agents) • Chronic toxicities can be either long-term effects that develop
(1) Alkylating Agents during or right after treatment and persist or late effects that are
• Damage DNA by causing breaks in the double-stranded helix. If absent during treatment and manifest later.
repair does not occur, cells will die immediately or when they try to
divide CELLS WITH RAPID RATE PROLIFERATION
• Bendamustine (Treanda), busulfan (Myleran), chlorambucil
(Leukeran) Cells with Rapid Rate of Effect of Cell Destruction
(2) Antitumor antibiotics Proliferation
• Bind directly to DNA, thus inhibiting the synthesis of DNA and Bone marrow stem cell Myelosupression (infection,
interfering with transcription of RNA bleeding, anemia)
• Bleomycin, dactinomycin (Cosmegen), doxorubicin (Doxil) Epithelial cells lining the Anorexia, mucositis, nausea,
(3) Nitrosureas GI tract vomiting, diarrhea
• Like alkylating agents, break DNA helix, interfering with DNA Neutrophils Leukopenia, Infection
replication, Cross blood brain barrier Ova, testes Reproductive Problems
• Carmustine (BicNU), lomustine ( Gleostine)
(4) Platinum Drugs RADIATION THERAPY
• Bind to DNA and RNA, miscoding information and/or inhibiting • Radiation is energy that is emitted from a source and travels
DNA replication and cells die
through space or some material. Delivery of high-energy beams,
• Carboplastin, cisplatin, oxaliplatin when absorbed into tissue, produces ionization of atomic particles.
• The energy in ionizing radiation acts to break the chemical bonds
METHODS OF ADMINISTRATION in DNA is damaged, causing cell death.
• Different types of ionizing radiation are used to treat cancer,
including electromagnetic radiation (e.g., x-rays, gamma rays) and
particulate radiation (e.g., alpha particles, electrons, neutrons,
protons).
• High-energy x-rays (photons) are generated by an electric
machine, such as a linear generator.

RADIATION DELIVERY
1. Teletherapy - The radiation source is external to the patient and
remote from the tumor site. It is also called external-radiation.
2. Brachytherapy - The radiation source comes into direct,
continuous contact with the tumor tissues for a specific period of
time.

NURSING MANAGEMENT FOR CHEMOTHERAPY & RADIATION

THERAPY
1. Hyperuricemia
1. Oral • Increased uric acid levels due to chemical-induced cell destruction
2. Intramuscular
• Can cause secondary gout and obstructive uropathy
3. Intravenous
Nursing Management
4. Intraarterial a. Monitor uric acid levels
5. Intracavitary (pleural peritoneal) b. Allopurinol may be given as a prophylactic measure
6. Intrathecal
c. Maintain increased fluid intake
7. Perfusion 2. Cardiotoxicity
8. Subcutaneous
• Some chemotherapy drugs can cause ECG changes and rapidly
9. Topical
progressive heart failure.
Nursing Management
EFFECTS OF CHEMOTHERAPY ON NORMAL TISSUE a. Monitor heart with ECG and cardiac ejection fractions
(1) Acute Toxicity b. Drug therapy may need to be changed for symptoms or
• Occurs during and right after drug administration. deteriorating cardiac function studies.
• It includes anaphylactic and hypersensitivity reactions, c. Administer antidysrhythmic drugs
extravasation or a flare reaction, anticipatory nausea and vomiting, 3. Pericarditis and Myocarditis
and dysrhythmias. • Inflammation form radiation injury
(2) Extravasation • Complication from chest wall radiation
• Intravenously given chemotherapy agents are additionally • May occur after one year after treatment
classified by their potential to damage tissue if they inadvertently • Side effect of some chemo drugs
leak from a vein into surrounding tissue (extravasation) Nursing Management
• Nonvesicants rarely produce acute reactions or tissue damage • a. Monitor for the manifestation of this disorder (e.g. dyspnea)
Irritant agents induce inflammatory reactions but usually cause no 4. Fatigue
permanent tissue damage • Anabolic processes result is accumulation of metabolites from cell
• Vesicants are those agents that, if deposited into the breakdown.
subcutaneous or surrounding tissues (extravasation), cause Nursing Management
inflammation; tissue damage; and possibly necrosis of tendons, a. Assess for reversible causes of fatigue and address them as
muscles, nerves, and blood vessels. indicated.
(3) Delayed effects b. Reassure patient fatigue is a common side effect of therapy.
• They include delayed nausea and vomiting, mucositis, alopecia, c. Encourage patient to rest when fatigued, to maintain usual
skin rashes, bone marrow suppression, altered bowel function lifestyle patterns, and as much as possible, and to pace activities
(diarrhea, constipation), and a variety of cumulative neurotoxicities. in accordance with energy level.
(4) Chronic Toxicities d. Encourage moderate exercise as tolerated
• Involve damage to organs, such as the heart, liver, kidneys, and
lungs.

2
5. Anorexia 12. Nephrotoxicity
• Release of TNF and IL-1 from macrophages has appetite • Exposure to nephrotoxic agents (cisplatin and high-dose
suppressant effect methotrexate) directly damages renal cells
• Therapy-induced GI effects (mucositis, nausea and vomiting, • Precipitation of metabolism breakdown (tumor lysis syndrome)
bowel problems) and anxiety, reduce appetite Nursing Management
Nursing Interventions a. Monitor BUN and serum creatinine levels
a. Monitor weight b. Avoid potentiating drugs
b. Encourage patient to eat small, frequent meals of high protein, c. Alkalinize the urine by adding sodium bicarbonate to IV infusion
high calorie foods. d. Give allopurinol or rasbicurase for TLS prevention
c. Gently encourage patient to eat, but do not nag. 13. Reproductive Problems
d. Recommend keeping a food diary to track daily calories and • Therapy damages cells of testes or ova
fluids. Nursing Responsibilities
e. Serve food in pleasant environment. a. Discuss possibility with patients before treatment initiation
6. Constipation b. Offer opportunity for sperm and ova banking before treatment
• Autonomic Nervous system dysfunction decreases intestinal for patient of childbearing age.
motility. 14. Anemia
• Caused by neurotoxic effects of plant alkaloids (vincristine and • Therapy causes bone marrow depression
vinblastine) • Malignant infiltration of bone marrow by cancer
Nursing Interventions Nursing Management
a. Teach patients to take stool softener as needed, eat high-fiber a. Monitor hemoglobin and hematocrit levels
foods, and increase fluid intake. b. Give iron supplements and eythropoeitin.
b. Teach patient to increase activity (e.g.) walking if tolerated. c. Encourage intake of foods that promote RBC production.
7. Diarrhea 15. Leukopenia
• From the denuding of the epithelial lining of intestines. • Chemotherapy or radiation therapy causes bone marrow
• Side effect of chemotherapy. depression.
• Follows radiation to abdomen, pelvis, lumbosacral areas. • Infection most frequent cause of morbidity and death in cancer
Nursing Interventions patients.
a. Give antidiarrheal drugs as needed. • Respiratory and genitourinary system are usual sites of infection.
b. Encourage low fiber, low residue diet. Nursing Management
c. Encourage fluid intake of at least 3L/ day a. Monitor WBC count, especially neutrophils.
8. Hepatoxicity b. Tell the patient to report temperature elevation and any other
• Toxic effects from chemotherapy drugs (usually transient and manifestations of infection.
resolve when drug is stopped) c. Teach patient to avoid large crowds and people with infections.
Nursing Management 16. Thrombocytopenia
a. Monitor the liver function tests • Chemotherapy causes bone marrow depression.
9. Nausea and Vomiting • Malignant infiltration of bone marrow crowds out the normal
• Release of intracellular breakdown products stimulates vomiting marrow.
center in brain • Spontaneous bleeding can occur with platelet counts less than or
• Drugs stimulate vomiting center in the brain equal to 20,000/ UL
• Radiation and chemotherapy destroy lining of GI tract. Nursing Management
Nursing Interventions a. Observe for signs of bleeding.
a. Encourage patient to eat and drink when nauseated. b. Monitor platelet counts.
b. Give prophylactic anti-emetics before chemotherapy and on as- 17. Alopecia
needed basis. • Chemotherapy or radiation to scalp destroys hair follicles.
c. Teach patients to take anti-emetics on a schedule basis for 2-3 • Hair loss usually is temporary with chemotherapy, but usually
days after highly emetogenic therapy. permanent with radiation
d. Use diversional activities if appropriate. Nursing Management
10. Stomatitis, Mucositis, Esophagitis a. Suggest ways to cope up with hair loss.
• Epithelial cells are destroyed by chemotherapy or radiation b. Avoid excessive shampooing, brushing, and combing of hair.
treatment when located in field. c. Avoid use of electric hair dryers, curlers and curling rods.
• Rapid cell destruction causes inflammation and ulceration d. Discuss impact of hair loss on self-image
Nursing Management 18. Chemotherapy-induced skin changes
a. Assess oral mucosa daily and teach patient to do this. • Acneiform eruptions
b. Encourage nutritional supplements if intake is decreasing. • Acral erythema
c. Be aware that eating, swallowing and talking may be difficult and • Hyperpigmentation
patient may need analgesics • Photosensitivity
d. Teach avoidance of irritating spicy, or acidic foods or too hot or • Telangiectasia
too cold food (extreme in temperatures.) Nursing Management
e. Encourage patient to use artificial saliva to manage dryness a. Alert patient to potential skin changes
(radiation) b. Encourage patient to pavoid sun exposure
f. Discourage use of irritants, such as tobacco and alcohol. c. Implement symptomatic management as needed depending on
g. Apply local anesthetics (viscous lidocaine) specific skin effect.
11. Hemorrhagic Cystitis 19. Radiation Skin Changes
• Chemotherapy (e.g. cyclophosphamide, ifosfamide) destroys cells • Erythema may develop 1 to 24 hours after a single treatment. It
lining in the bladder. generally occurs progressively as the treatment dose accumulates.
• Side effect of radiation when in the treatment field. • It is an acute response followed by dry desquamation
Nursing Management • If the rate of cell sloughing is faster than the ability of the new
a. Encourage increased fluid intake 24-72 hours after treatment is epidermal cells to replace dead cells, a wet desquamation occurs
tolerated. with exposure of the dermis and weeping of serous fluid
b. Monitor for urgency, frequency and hematuria. Nursing Management
c. Give cytoprotectant agent, Mesna (Mesnex) and hydration a. Dry Desquamation
d. Give supportive care agents to manage symptoms - Do not use heating pads, icepacks, and hot water bottles in the
treatment field.
3
 - Avoid constricting garments, rubbing, harsh chemicals, and 3. CD20 Monoclonal Antibodies
deodorants, since they may traumatize the skin. • Bind CD20 antigen, causing cytotoxicity and radiation injury
- Lubricate dry skin with a nonirritating lotion emollient that • Ibiritumomab tiuxetan/yttrium-90 (Zevalin)
contains no metal, alcohol, perfume, or additives 4. CD52 Monoclonal Antibody
- Calendula ointment and topical hyaluronic acid cream are • Bind CD52 antigen (found on T and B cells, monocytes, natural
effective for managing radiation dermatitis killer cells, neutrophils)
b. Wet Desquamation • Alentuzumab (Campath)
- Skin care to manage moist desquamation includes keeping 5. Angiogenesis Inhibitors
tissues clean with normal saline compresses or modified Burow’s • Bind vascular endothelial growth factor (VEGF), thereby inhibiting
solution soaks angiogenesis
- Protect the skin from further damage with moisture vapor– • Bevacizumab (Avastin)
permeable dressings or Vaseline petrolatum gauze
• Pazopanib (Votrient)
20. Cognitive changes “chemo brain” 6. Human Epidermal Growth Factor Receptor-2 (HER-2)
• Occur during and after treatment (especially) with chemotherapy • Monoclonal antibody to HER-2 that attaches to antigen. It is taken
• Problems with concentration, memory lapses, trouble into the cells and eventually kills them •
remembering details, taking longer to finish tasks
• Pertuzumab (Perjeta)
• May happen quickly and last a short time. Some people have mild 7. Kinase Inhibitors
long-term effects
• EGFR Tyrosine Kinase (TK) inhibitors
Nursing Management
• Inhibit epidermal growth factor receptor (EGFR) TK
a. Teach patients to:
• Cetuximab (Erbitux). Erlotinib (Tarceva)
- Use daily planner
8. Proteasome Inhibitors
- Get enough sleep and rest.
- Exercise brain (learn something new, do word puzzles) • Inhibit proteasome activity, which functions to regulate cell growth.
- Focus on one thing (no multitasking) • Bortezimib (Velcade)
21. Intracranial Pressure • Carfilzomib (Kyprolis)
• May result from radiation edema in the central nervous system
Nursing Management NURSING MANAGEMENT
a. Monitor neurologic status. • Monitor for side effects: IFN-α may cause mental slowing,
b. May be controlled with corticosteroids. confusion and lethargy; combination therapy of 5-fluorouracil or IL-
22. Peripheral neuropathies 2 and IFNα may cause severe flu-like symptoms, with chills and
• Paresthesias, areflexia, skeletal muscle weakness and smooth fever of 39.4ºC to 41.1ºC, nausea, vomiting, diarrhea, anorexia,
muscle dysfunction can occur as a side effect of plant alkaloids, severe fatigue and stomatitis; erythropoietin may cause acute
taxanes and cisplatin. hypertension.
Nursing Management • Monitor enzymes and other appropriate biochemical indicators for
a. Monitor for manifestations of patients on these drugs acute alterations in renal, cardiac, liver or gastrointestinal
b. Consider temporary chemotherapy dose interruption or functioning, which can be side effects of IL-2.
reduction until symptoms improve. • Evaluate response to therapy by conducting a thorough evaluation
c. Antiseizure may be considered of the person’s symptoms.
• Assess the person’s coping behaviors and teach new strategies as
IMMUNOTHERAPY & TARGETED THERAPY needed
. • Manage fatigue and depression.
IMMUNOTHERAPY • Encourage self-care and participation in decision making.
• Immunotherapy uses the immune system, the body’s main • Provide close supervision for people with altered mental
defense against infection and disease, to fight cancer. functioning, either by caretakers or through frequent nursing visits
to the person’s home.If the person is unable to manage alone,
• Immunotherapy can (1) boost or manipulate the immune system
teach medication administration and care of equipment to
and create an environment that is not conducive for cancer cells to
caregivers.
grow or (2) attack cancer cells directly.

IMMUNOTHERAPIES & TARGETED THERAPIES HEALTH EDUCATION FOR THE PERSON & FAMILY
• Minimize symptoms by managing fever and flu-like symptoms:
increase fluid intake, take analgesic and antipyretic medications,
and maintain bed rest until symptoms abate
• Seek help for serious problems not managed by usual means,
such as dehydration from diarrhea.
• Use correct techniques for providing subcutaneous injections.
• Identify how to work and care for ambulatory pumps when
medication is administered through an inter- catheter or vascular
access Immunotherapy can consist of various substances used
alone, such as IL -2, or combination biotherapy, such as IFN-α
with 5-fluorouracil
1. Cytokines
• Inhibit DNA and protein synthesis. Supress cell proliferation. HORMONE THERAPY
• Increase cytotoxic effects of NK killer cells. • Stimulate proliferation • When given as a cancer treatment, drugs (hormone therapy) can
of T and B cells block the effects of the hormone and stop the growth of cancer
• Activate NK cells cells.
• α – Interferon (intron A) • In addition to drug manipulation of hormones, surgical
2. Vaccines interventions (oophorectomy, castration) can be used to remove
• Live attenuated strain of Mycobacterium bovis induces immune the effects of the hormone on cancer growth.
response. Use intravesically to treat bladder cancer
• BCG vaccine 1. Androgen Receptor Blockers
• Vaccines against prostate cancer that stimulates the immune • Selectively attach to androgen receptors, blocking androgen from
system against cancer • Sipuleucel-T (Provenge) binding. Inhibits tumor growth.
• flutamide, bicalutamide (casodex), enzalutamide (Xtandi)
4
2. Aromatase Inhibitors
• Inhibit aromatase, thus preventing the production of estrogen.
• anastrozole (Arimedex), letrozole (Femara)
3. Corticosteroids
• Disrupt the cell membrane and inhibit synthesis of protein.
Decrease circulating lymphocytes, inhibit mitosis, depress immune
system, increase sense of well-being.
• Cortisone, dexamethasone, hydrocortisone
4. Estrogens
• Interfere with the effect of testosterone
• Estrogen, estradiol, estramustine (Emcyt)
5. Estrogen Receptor Blockers
• Selectively attach to extrogen receptors, blocking estrogen from
binding. Inhibits tumor growth
• Fulestrant (Faslodex), tamoxifen, toremifine
6. Estrogen Receptor Modulator
• Has both estrogenagonistic effects on bone and
estrogenantagonistic effects on breast tissue
• Raloxifene (Evista)

5
 MEDICAL-SURGICAL NURSING┃SEMIFINALS┃TRANS 10
LIVER CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃DEC 06 2021
TRANSCRIBED BY ZARAHTESS P. RUBIO

LIVER CANCER 5. Exposure to alfatoxin

• Hepatic tumors may be malignant or benign • Alfatoxin it is a metabolite of the fungus aspergillus flavus. This is
• Benign liver tumors were uncommon until use of oral especially true in areas where HCC is endemic such as in Asia and
contraceptives were in widespread use. It may have predisposed Africa.
the formation of the benign liver tumors or hepatic tumors. • Alfatoxin and other similar toxic molds can actually contaminate
• Now, benign liver tumors, such as the hepatic adenomas occur most food, such as ground nuts and grains, it may also act as a
frequently in women in their reproductive years who are taking oral carcinogen, especially with HBV
contraceptives (Greenberger et al.,2015) • The risk of getting contaminated with the alfatoxin is greatest when
• Few cancers actually originate in the liver most of the time. The these foods are actually stored in unrefrigerated areas, especially in
cancer metastasized in the liver from other origins or other cancer tropical or sub-tropical climates.
sites.
CLINICAL MANIFESTATIONS OF HEPATOCELLULAR
ANATOMY AND PHYSIOLOGY CARCINOMA (HCC)
• Liver is located on the upper right side of the body, behind the lower 1. Pain
ribs. • It is a continuous dull ache in the right upper quadrant, epigastrium,
or back.
• This is considered to be the early manifestation of HCC
2. Enlarged liver and irregular shape upon palpation
3. Weight loss, loss of strength, anorexia, and anemia
4. Jaundice
• May indicate that the bile ducts or the larger bile ducts are occluded
by the pressure of the malignant nodules that are located in the
hilum of the liver.
• If there is an obstruction, the bile cannot go out there by causing the
jaundice.
5. Ascites
• It is developed if such nodules or the HCC will obstruct the portal
veins or if tumor tissue is seeded in the peritoneal cavity.

FUNCTIONS: DIAGNOSTIC TESTS OF LIVER CANCER

• Storing nutrients 1. X-rays
• Removing waste products and worn-out cells from the blood 2. Liver scans
• Filtering and processing chemicals in food, alcohol, and 3. CT scans
medications. 4. Ultrasound studies
• Producing bile, which is a solution that helps digest fats and 5. MRI
eliminates waste products. 6. Arteriography and laparoscopy – these are done to determine the
extent of the cancer and this will help with the staging of the cancer
PRIMARY LIVER TUMORS 7. PET (Positron Emission Tomography) scan – are used to
75% That Accounts The Primary Liver Tumor evaluate a wide range of metastatic tumors of the liver.
Hepatocellular carcinoma (HCC)
• It is the third leading cause of cancer related mortality worldwide, DIAGNOSTIC FINDINGS OF LIVER CANCER
which suggests that having HCC will be fatal 1. Increased serum levels of bilirubin
• Usually non-resectable, which means that it is usually found on its 2. Increased alkaline phosphatase
late stage, it grows rapidly, and it metastasizes rapidly, however, if 3. Increased AST (Liver Function Test)
it is found early, resection of the primary liver cancer may be 4. Increased GGT
possible, however, early detection is not common. 5. Increased lactic dehydrogenase
6. Leukocytosis or the increase in WBC
25% That Accounts The Primary Liver Tumor 7. Erythrocytosis
• Fibrolamellar carcinoma 8. Hypercalcemia
• Angiosarcoma 9. Hypoglycemia
• Hepatoblastoma 10. Hypocholesterolemia – this is because if there is no bile, there is
• Cholangiocellular carcinoma going to be no absorption of the cholesterol
11. Elevated alpha-fetoprotein – alpha-fetoprotein is the tumor marker
• Combined hepatocellular and cholangiocellular carcinoma
for the liver cancer.
12. Biopsy – the confirmation of the tumor cystology can be done by
RISK FACTORS OF HEPATOCELLULAR CARCINOMA (HCC)
this biopsy under imaging guidance or laparoscope.
1. Cirrhosis
2. Chronic infection with HBV and HC
3. Exposure to certain chemical toxins
• Such as vinyl chloride and arsenic
4. Cigarette smoking with alcohol use
• Especially if these two are combined together

1
 MEDICAL MANAGEMENT OF LIVER CANCER
1. Radiation Therapy 4. Percutaneous Biliary or Trans-hepatic Drainage
• The use of tele-therapy or the external beam radiation for the • It is used to bypass biliary ducts
treatment of liver tumors is limited because the hepatocytes or the obstructed by liver, pancreatic, or
urine liver cells are actually radiosensitive and there will be a bile duct tumors in patients who
destructing of the normal liver parenchyma. have inoperable tumors or are
• TARE (Trans-arterial Radioembolization) considered poor surgical risk.
- The doctor will insert a micro-catheter to the liver and release or • It is use to reestablish biliary
infuse millions of particles of high dose radioisotopes, which drainage, relieve pressure and
releases the radiation into the liver or near the tumor site. pain from the buildup of bile behind
- The main advantage of this is that it is going to spare the normal the obstruction, and decrease
hepatocytes, so it is more specific to the tumor cells. The more pruritus and jaundice.
specific, the more advantageous will that be for the patient. • The word drainage means that the
2. Targeted Therapy gallbladder is going to be drained.
• Targeted molecular therapy often uses the drug sorafenib The bile is going to get drained and
(Nexavar), this is an anti-angiogenesis drug because angiogenesis the collection bag is where the bile
is one of the ways wherein a tumor can actually proliferate. or the excess fluid is going to be
• By preventing angiogenesis or the formation of circulation for the drained.
tumor, you are also preventing the proliferation of the abnormal • The purpose of this is to relieve the
cells. pressure and pain from the build
3. Chemotherapy the buildup of bile behind the
a. Systemic Chemotherapy obstruction. This is also to relieve
- This is for cases wherein the liver cancer is already advanced or the jaundice and the pruritus of the
in the metastatic state. This is more for the metastatic stage of liver patient.
lesions
b. Trans-arterial chemoembolization (TACE) SURIGICAL MANAGEMENT OF LIVER CANCER
- It is a minimally invasive image guided treatment for cancerous 1. Surgical Resection
liver tumors that combines embolization and chemotherapy. • It is the treatment of choice
- During TACE, an interventional radiologist uses fluoroscopy to when your HCC is confined to one
guide a thin flexible tube called a catheter into a pinhole at the hip lobe of the liver and the function of
or wrist and through the blood vessels to the liver the remaining liver is considered
- The catheter is use to inject tiny beads coated with chemotherapy adequate for postoperative
into the blood vessels that lead to the cancer. recovery.
- The beads deliver a high dose of chemotherapy directly to the • The surgeons are capitalizing on
cancer with minimal effect on nearby healthy tissue. with this is the regenerative
- The beads are designed to shrink the tumors by blocking the blood capacity of the liver or the ability of
supply that feeds them, this process is called embolization. It also the liver to actually regenerate.
concentrates the chemotherapy around the tumors Some surgeons even have
successfully removed 90% of the
OTHER DELIVERY SYSTEMS OF CHEMOTHERAPY: liver.
• In most cases, the hepatic artery • There are also cases where in the
catheter has been inserted surgical resection may cannot be
surgically and has a prefilled done, especially in cases wherein there is already cirrhosis, if there
infusion pump implanted is cirrhosis, it can actually limit this surgical option.
subcutaneously that delivers a 2. Local Ablation
continuous chemotherapeutic • In patient who are not candidates for resection or transplantation,
dose until completed. ablation of the HCC may be accomplished by chemicals such as
ethanol or by physical means such as radiofrequency ablation (most
frequently used local ablative therapy) or microwave coagulation
3. Liver Transplantation

• A hepatic artery port may also

be inserted to provide access for
intermittent chemotherapy
infusion. This port dwells under
the skin, but because it provides
direct arterial access, it is not
used for continuous infusion
therapy in the home • This treatment involves removing the liver and replacing it with a
environment; the access line is healthy donor organ.
discontinued once the • This actually offers good patient outcomes. The candidate for this
chemotherapeutic agent has must meet the selection criteria which include the small early-stage
been infused. lesions.
• Milan Criteria: The patient must have a single tumor, measuring
less than 5 centimeters, or have three or fewer lesions with none
over 3 centimeters in size.
• A portion of the donor's liver is going to be transplanted on the
patient and the recipient's liver which has the tumor is going to be
removed.
• This has a good prognosis, studies report decreased recurrence
rates of the primary liver after transplantation with improvement in
2
 four-year survival rates to approximately 85% which is already
considered good.
NURSING MANAGEMENT OF LIVER CANCER
SURGERY
• For patients with liver cancer anticipating surgery, support,
education, and encouragement are provided to help them prepare
psychologically for the surgery.
• Watch out for vascular complications and respiratory and liver
dysfunction.
• Metabolic abnormalities require careful attention.
• Because extensive blood loss may occur as well, the patient
receives infusions of blood and IV fluids. Prepare the patient for
blood transfusion.
• The patient requires constant, close monitoring and care for the first
2 to 3 days, similar to postsurgical abdominal and thoracic.

CHEMOTHERAPY
• The nurse educates the patient to recognize and report the potential
complications and side effects of chemotherapy and the desirable
and undesirable effects of the specific chemotherapy regimen.
• The nurse also emphasizes the importance of follow-up visits to
assess the response to chemotherapy and radiation therapy.

HEPATIC ARTERY CATHETER WITH PUMP

• In addition, if the patient is receiving chemotherapy on an outpatient
basis, the nurse explains the patient’s and family's role in managing
the chemotherapy infusion and in assessing the in the infusion or
insertion site.
• The nurse would also have to advise the patient to resume the
routine activities as soon as possible, but the nurse should also warn
the patient about falls or activities that could possibly damage the
pump or the site.

HEPATIC BILIARY DRAINAGE SYSTEM

• Provide reassurance and instruction can help reduce their fear that
the catheter will fall out easily
• The patient and the family also require education on catheter care,
including instructions on how to keep the catheter site clean and dry
and how to assess the catheter and its insertion site.
• Irrigation of the catheter with sterile normal saline solution or water
may be prescribed to keep the catheter patent and free of debris.
The key word here is that we have to keep the catheter pattern,
otherwise the bile will not be able to be drained or the excess bowel
will not drain.
• The patient and the caregivers are taught proper technique to avoid
introducing bacteria into the biliary system or catheter during
irrigation. It has to be a sterile technique.
• They are instructed not to aspirate or draw back on the syringe
during irrigation in order to prevent entry of irritating duodenal
contents into the biliary tree or the catheter.
• The patient and caregivers are also instructed about the signs of
complications and are encouraged to notify the nurse or primary
provider if problems or questions arise.

HEPATIC ARTERY PORT

• Such a port has an internal one-way valve; therefore, it is not
aspirated for blood return before the infusion is initiated
• The patient is instructed to assess the port site between infusions
and to note and report any signs of infection or information. For any
foreign object that is being attached to the patient that actually
predisposes a patient to infection, that is why if there is any
contraption, and if the patient has any contraption, he/she should be
monitored for infection.

3
 MEDICAL-SURGICAL NURSING┃FINALS┃TRANS 11
PROSTATE CANCER
MRS. APRIL LOVE R. OJA, RN, MAN ┃DEC 06 2021
TRANSCRIBED BY TOM CUENCA & CAMILLE BUTAO

RISK FACTORS OF PROSTATE CANCER Disadvantages:

1. Race: African-American men 1. Missed chance at cure
2. Age: Incidence of prostate cancer increases after the age of 50 and 2. Risk of metastasis
more than 70% of cases occur in men older than 65 years old 3. Subsequent need for more aggressive treatment
3. Familial predisposition: Having a brother or father diagnosed with 4. Anxiety about living with untreated cancer
prostate cancer especially at a young age 5. Need for frequent monitoring
4. Genetic mutations: BCRA2 mutations or S-transferase (GSTPI)
gene SURGICAL MANAGEMENT OF PROSTATE CANCER
5. Diet containing excessive amounts of red meat or dairy products 1. Radical Prostatectomy:
that are high in fat Traditional method, it is the
6. Endogenous hormones, such as androgens and estrogen, may removal of the entire prostate
also be associated with the development of prostate cancer gland, seminal vesicles and part
of the bladder neck
CLINICAL MANIFESTATIONS OF PROSTATE CANCER a. Retropubic prostatectomy:
• Early stages rarely produce symptoms, however, as the tumor Performed because it allows
progress, it may cause an obstruction in the urethra adequate control of bleeding,
• Signs of urinary obstructions: visualization of the prostate bed
a. Difficulty and frequency of urination and bladder neck, and access to
b. Urinary retention lymph nodes
c. Decreased size and force of the urinary stream b. Perineal prostatectomy:
• Blood in the urine or semen and painful ejaculation Often preferred for older men or
those with poor surgical risks.
• Sexual dysfunction
This approach requires less time
• Symptoms of metastasis:
and involves less bleeding.
a. Backache
2. Laparoscopic Radical Prostatectomy
b. Hip pain
c. Perineal and rectal discomfort • It is a minimally invasive type for cure of patients who have a
PSA level of less than 10ng/mL and who have had no previous
d. Anemia
hormone therapy or abdominal surgeries
e. Weight loss
f. Weakness • Laparoscopic surgery differs from traditional open surgery by
g. Nausea making five small incisions as opposed to one large incision to
h. Oliguria (decreased urine output) perform the surgery
i. Spontaneous pathologic fractures 3. Radical Prostatectomy Post-Op
• Contraptions: Large indwelling catheter with 20 ml or 30 ml
DIAGNOSTIC FINDINGS OF PROSTATE CANCER balloon in the bladder via the urethra.
• Adverse Outcomes:
• If it is detected early, the likelihood of cure is high.
o ED and urinary incontinence (the patient is not able
1. Digital Rectal Exam: Early cancer may be detected as a nodule
to control his bladder)
within the gland or as an extensive hardening in the posterior lobe.
o Sexual function after surgery tends to return
The procedure should be done by the same examiner so that it will
gradually over at least 24 months or more
be easier for the examiner to compare previous results of
o Phosphodiesterase type 5 (PDE5) inhibitor – may
examination to the present examination
help improve sexual function
2. Prostate Specific Antigen (PSA): An onco-fetal antigen which will
• Problems with urinary control
show elevated levels if the patient has prostate cancer
o May occur during the first few months after the
3. Histologic Examination: Done via TURP (transurethral resection
surgery.
of the prostate), open prostatectomy or ultrasound-guided
o Advise: Kegel exercises
transrectal needle (prostate biopsy). TURP is performed through the
use of a resectoscope which is inserted via the urethra and will
remove a tissue in the prostate which will be sent to the laboratory MEDICAL MANAGEMENT
for examination. In ultrasound-guided transrectal needle (prostate
biopsy), a biopsy needle is attached to the ultrasound probe which RADIATION THERAPY
will get some tissue sample from the prostate which will be sent to • There are two types of radiation therapy and both can be done for a
the laboratory for examination. patient with prostate cancer.
• External or internal radiation therapy may be used in the treatment
MEDICAL MANAGEMENT OF PROSTATE CANCER of prostate cancer or palliation of late-stage symptoms.
• The treatment of prostate cancer will depend on the patient’s life
expectancy, the symptoms, the risk of recurrent after definitive (1) External Beam Radiation Therapy (EBRT)
treatment, the size of the tumor, the Gleason score, the PSA level, • Comes from a source outside the body.
likelihood of complication and the preference of the patient. • Patients are usually treated 5 days each week for 6 to 9 weeks.
Nonsurgical Watchful Waiting: Involves actively monitoring the
course of disease and intervening only if the cancer progresses or
• if symptoms warrant other intervention. It is an option for patients Complications of EBRT may include:
with life expectancy of less than 5 years and low-risk cancers. • ED or Erectile Dysfunction
Advantages: • Acute radiation cystitis
1. Absence of side effects of more aggressive treatment • Radiation proctitis
2. Improved quality of life, avoidance of unnecessary treatment
3. Decreased initial costs
1
 INTERNAL RADIATION THERAPY (BRACHYTHERAPY) • Relieve Discomfort
o Bed rest and analgesics
o Insertion of indwelling catheter. In case the patient is still
experiencing urinary retention because of the obstruction
caused by the tumor, an indwelling catheter can be
inserted.
• Provide Education
o Teach patient about the probable location of the surgical
incision, the use of an indwelling urinary catheter,
placement of drains, and the possibility of temporary ED.
Patients have to know these things before they sign the
consent.
o The provision of education is done not only to reduce
anxiety but also as part of acquiring or getting the informed
consent of the patient.
• Prepare the Patient
o The patient can be at risk for developing VTE or Venous
Thromboembolism because the patient could be placed
in a lithotomy position especially if it’s the perennial
approach of prostatectomy that is going to be done.
o We have to give patients anti-embolic stockings (if
• Can be delivered by implanting low-dose radiation seeds directly patient will be placed in a lithotomy position) this is to
into and around the prostate gland, prevent the venous thromboembolism.
• In the picture above, the radiation sees will be releasing the o Enema can be administered prior to the surgery. Because
radiation directly into and around the prostate gland. after the surgery the patient is actually not allowed to strain
when defecating because it could cause tension on the
HORMONE THERAPY incision site.

2. Post-operative Care
• Relieve Pain. It is expected that there is an incision site, the
patient is going to have pain. It is important to assess this pain,
provide comfort measures, administer drugs like analgesics,
and do non-pharmacological measures like deep breathing
exercises, relaxation, diversional activities.
• Monitor for Potential Complication
o Hemorrhage. Especially during the first 24 hours.
o Infection. Some of the signs of infection are the
purulent discharge in the incision site and fever.
o Venous Thromboembolism. This can manifest as
leg pain or tenderness of the thigh or calf.

3. Ambulatory Care
• Teach catheter care if patient is discharged with an
• Another option that the doctor may recommend or include in the indwelling catheter
treatment of prostate cancer. The rationale behind this is because, o Keep collecting bag lower than bladder at all times so
prostate tumors are hormone dependent, these tumors can be that it could drain properly.
reduce or have their growth slowed through androgen deprivation. o Keep catheter securely anchored to the inner thigh or
the abdomen so that it won’t get dislodge.
One of the procedures that can be done is the: • Watch out for signs of infection
• Bilateral Orchiectomy (surgery) o Bladder spasms
o Removal of the testicle. o Fever
o To remove the testosterone influence. o Hematuria
• Luteinizing Hormone-Releasing Hormone (LH-RH) • If urinary incontinence is a problem
o Agonists or antiandrogens (drugs) can be given. o Kegel Exercises

Side Effects of Hormone Therapy may include: 4. Palliative and End-of Life Care
• Hot flashes (this are for patients who are in advanced care)
• Gynecomastia (breast development) • Common Problems:
o Fatigue
CHEMOTHERAPY o Bladder outlet obstructions
o Ureteral obstructions
• Systemic cytotoxic chemotherapy is an option for patient whose o Severe bone pain/fractures – because of the
cancer has spread and for whom other therapies have not worked.
metastasis in the bone.
• Commonly used agents for prostate cancer include docetaxel o Spinal cord compression – this is because of the
(Taxotere), cisplatin (Platinol), and etoposide (VP-16, VePesid). metastasis in the spinal cord.
• This is for those who are in advanced stages because surgery o Leg edema
cannot do the cure anymore, so that is why the healthcare providers • Pain Management
are trying to reach those cancer cells that are already in the other o Opioid and non-opioid analgesics
sites. o Relaxation, breathing exercises (non-
pharmacological measures)
NURSING MANAGEMENT
1. Provide Preoperative Care
• Reduce anxiety. One way of doing that is to educate the patient
about the diagnosis and also about the possible outcomes and let
them be familiarized with the routines in the hospital.