Oncology 2

Oncology
The Study of Tumours and

their treatment
2/1/15
compiled by Isaac Amankwaa
Outline of presentation
Definitions
Incidence of cancer
Neoplasm/tumours
Aetiology
Nomenclature
Pathophysiology
Carcinogenesis
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Definitions
1. Oncology: study of tumors.
2. Neoplasm: an abnormal mass of tissue as a
result of neoplasia or cell multiplication.
3. Neoplasia is the abnormal proliferation of
cells
4. Cancer: A malignant growth. Related terms:
malignant tumours
& neoplasms
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Terminologies
5. Anaplasia: cells that lack normal cellular

characteristics.
6. Hyperplasia: an abnormal increase in
the number of cells
7. Metaplasia: transformation of one tissue
to another
8. Dysplasia: an abnormality in
development
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Incidence
A leading cause of death worldwide,

accounting for 7.6 million deaths
(WHO, 2008)
Affect all ethnic groups and all ages
common in the aged (above 65 yrs).
More men die of cancer than women.
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The 10 leading cancer types
(American Cancer Society, 2005)

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Tumors:Neoplasms
Definition
A neoplasm is an abnormal mass of tissue,
the growth of which exceeds and is
uncoordinated with that of the normal
tissues and persists in the same excessive
manner after cessation of the stimuli
which evoked the change - Willis
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Types of Neoplasm
There are two major types:
Benign
Malignant neoplasm
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Benign Tumors
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If cells
LOOK GOOD, they are probably going to

BEHAVE
GOOD
Malignant
Tumors
If cells LOOK BAD, they are probably going to

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BEHAVE BAD
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Malignant tumors
Aka cancer
Cancer is derived from
the Greek word for crab
Cancers are examples
of tumors
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Aetiology /Carcinogens
Physical agents e.g. tobacco and

radiation
Chemicals e.g. Alcohol & soot
Genetic factors
Infectious agents e.g. hepatitis B,

Dietary factors like fats & red meat.
Hormonal factors e.g. oral
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Naming Tumors: Benign

Tumors
Examples include:
Named according
to the tissues from
1. Chondroma: cartilaginous
tumor
2. Fibroma- fibrous tumor

which they
3. Osteoma-bone tumor
originate and
4. Lipoma-tumor of the fat
tis.
include the suffix
5. Glioma-?
oma
6. Leimyoma-?
i.e. type of tissue Some tricky ones
plus oma
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Epithelial lining -papilo

Glands-adeno
e.g. Adenoma
Naming of tumors:
malignant
Sarcomas: mesenchymal tumor

chrondrosarcoma: cartilaginous tumor
fibrosarcoma: fibrous tumor
osteosarcoma: bone tumor
Carcinomas: epithelial tumors

adenocarcinoma: gland forming tumor
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Pathophysiology of cancer
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Characteristics of Normal Matured

Cells
Cells normally
differentiate, grow,
mature and divide.
These are regulated
processes, balanced
in a healthy system
such that cell birth is
nearly equal to cell
death
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Pathophysiology
Characteristics of Cancer
cells
Differ from normal cells
Ignore normal growth-
regulating signals, proliferate

and grow uncontrollably.
The cells become invasive,
infiltrate adjacent structures

destroying surrounding
tissues and organs.
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Genes Involved in cancer

development
Proto-oncogenes
In normal cells
Code for proteins involved in the stimulus of
cell division
If altered, may form oncogenes

Alone, do not cause malignant cancer
Require other mutations, including one in a
tumor suppressor gene
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development
Tumor Suppressor Genes
Stop cell growth and division;
prevent cancer formation
May prevent expression of
oncogenes
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development
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Pathophysiology
There are two major dysfunctions
associated with the process of
cancer:
Defective cellular proliferation
Defective cellular differentiation.
2/1/15
1. Defective cellular proliferation

Normal physiology
Stem cells proliferate and differentiate to
produce various cells of the body
A state of dynamic equilibrium maintained
Proliferation occurs only:
in cellular death
In increased physiologic need for more cells.
2/1/15
1. Defective cellular
proliferation
In the case cancer cells, there is:
A. Loss of Contact Inhibition
Normal cells respect the boundaries of cells. This is
known as contact inhibition
Malignant cells have no contact inhibition
B. Respond differently to the signals that regulate

the state of dynamic equilibrium
Cancer cells therefore divide indiscriminately

and may produce more than 2 cells at a time.
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2. Defective cellular differentiation

Cellular differentiation
All Body cells derived
from fertilized ova (STEM
CELL)
They have potential to
differentiate to perform
all body functions.
This potential is repressed
by differentiation process
Matured cells only
perform specific
functions.
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2. Defective cellular
differentiation
Proto-oncogenes
Normal genes that regulate cell growth
and differentiation
May become oncogenes by mutation
Oncogenes have potential to cause
cancer
Tumor suppressor genes.

Tumor suppressor genes suppress growth.
Mutations can turn these normal

genes into tumour inducing genes.
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Carcinogenesis
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CARCINOGENESIS
Tumor development goes through 3

stages;
1. Initiation
2. Promotion
3. progression
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1.Initiation
Alteration of cells genetic

structure resulting from:
1. An inherited mutation
2. exposure to carcinogens.
Altered cells may develop into a

clone of neoplastic cells.
2/1/15
Promotion
Characterized by reversible
proliferation of the altered cells.
Activities of promoters (e.g. cigarette
smoking) are reversible
Some carcinogens (Complete
carcinogens) are capable of initiating
and promoting cancer eg is cigarette
smoke.
Latent Period: The period between
the initial genetic alteration and the
actual clinical evidence
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PROGRESSION
The final stage of tumor

development
Characterized by:
Increased growth rate of the tumor,

increased invasiveness and
metastasis (spread of cancer to
distant organs).
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Characteristics of cancer
cells
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Cancer cells are abnormal in their

growth and appearance
2/1/15
Cancer cells undergo

metastasis
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Cancer cells undergo

angiogenesis
2/1/15
Other characteristics of cancer cells

They lack differentiation
They have abnormal nuclei
The cell membrane contains tumor-specific
antigens e.g. prostate specific antigen
(PSA)
Malignant cells are less adhesive and dont
adhere to adjacent cells easily
2/1/15
Difference
Cancer Cells
Normal cell
1. Nondeifferentiated
2. Abnormal nuclei
3. Do not undergo
apoptosis
4. No contact inhibition
5. Disorganised
6. Undergo metastasis
and angiogensis
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1.
2.
3.
4.
Well-deferentiatated
Normal nuclei
Undergo apoptsosis
Contact inhibition
present
5. One organized layer
Classification of cancer
Classified according to
Anatomic site
histology/grading
extent of disease/staging.
2/1/15
Anatomic site
Two classes identified:
1. Carcinomas originate from
Ectoderm-skin and glands
Endoderm -mucus membranes lining GIT, GU tract &
RT
2. Sarcomas originate from

mesoderm :connective tissue, muscles, bones
and fat
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GRADING: degree of
differentiation
1.GRADE I: Mild dysplasia
Cells differ slightly from normal cells

well differentiated.
2. GRADE II: moderate dysplasia
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Cells more abnormal
moderately differentiated.
GRADING: degree of
differentiation
3. GRADE III: Severe dysplasia
Cells very abnormal
poorly differentiated.
4. GRADE IV : Anaplasia
Cells immature & primitive
undifferentiated.
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STAGING: Classification by extent of

disease
No unique staging system

Anatomic extent of the malignant disease
STAGE 0: Cancer in situ
STAGE I:
Tumor localized to the tissue of origin
STAGE II: Limited local spread

STAGE III: Extensive local and regional spread
STAGE IV: Metastasis
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STAGING: TNM classification

Used to determine the anatomic extent of the disease
Tumor-node-metastasis (TNM) system used for most cancers
Based on three parameters:
1. T
Tumor size and invasiveness
2. N presence or absence of regional spread to lymph nodes

3. M metastasis to distant organ sites
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Primary Tumor (T)
T0 No sign of primary
tumor
Tx
Tumor cant be found or
assessed
Tis Carcinoma in situ

T1, T2, T3, T4: Increasing size
and/or extension of primary tumor
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Regional Lymph Nodes (N)
N0
No evidence of tumor cells in regional
lymph nodes
Nx
Regional lymph nodes cannot be
assessed
N1, N2, N3, Increasing involvement of
regional
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lymph nodes
Distant Metastasis (M)
M0
No distant metastasis
Mx
Distant metastasis cannot be
assessed
M1
2/1/15
Distant metastasis
Common manifestations of
cancer
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1. Pain:
2. Hemorrhage
3. Bone marrow suppression
4. Infection
5. Anorexia-cachexia syndrome
6. Unexplained rapid weight loss
7. Disruption of function
2/1/15
WARNING SIGNS OF
CANCER
2/1/15
The acronym CAUTION is used

C= change in bowel and bladder habit
A= A sore that does not heal
U= Unusual bleeding or discharge
T= Thickening lump in the breast or other
body parts
I= Indigestion or difficulty in swallowing
O=Obvious change in wart or mole
N= Nagging cough or hoarseness
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Diagnosis of
Cancer
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Diagnosis may involve

1. Health history
2. Physical examination
3. Identification of risk factors
4. Specific diagnostic studies
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History taking
family and personal
history of cancer,
exposure or use of
carcinogens
Lifestyle: e.g.
chronic alcohol
intake
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Physical Examination
2/1/15
Identification of risk factors
2/1/15
Specific diagnostic studies include

1. Tissue biopsy/Cytology
study
9. CT scan
2. Chest X-rays
10.Positron emission
3. Complete blood count

4. Tumor marker identification
5. Radiologic studies
6. Endoscopy
7. Liver function tests
2/1/15
8. MRI
tomography (PET) scan

11.Fluoroscopy
12.Nuclear medicine
imaging
Biopsy
The surgical removal of a small piece
of tissue to determine if the area is
cancerous.
Examples of Biopsies
Needle biopsy
Incisional biopsy
Excisional biopsy
Curettage biopsy
Endoscopic biopsy
2/1/15
Needle Biopsy
A needle is
inserted through
the skin to the
suspicious area
and cells are
extracted
2/1/15
THERAPIES USED IN
TREATING CANCERS
2/1/15
Goal for therapy

1. Cure
2. control
3. palliation
2/1/15
Approaches used in cancer

management
1. Local therapy
Surgery
radiation therapy
2. Systemic treatment
chemotherapy.
Hormonal therapy.
Monoclonal antibodies.
Radioactive material
3. supportive care
4. non-conventional therapy.
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SURGERY
The definitive treatment
2/1/15
Introduction
Ideal and commonly used method.
First modality used successfully in

the treatment of cancer.
2/1/15
AIMS OF SURGERY
1.
Diagnosis
2.
Primary method of treatment

(curative)
3.
Palliation and reconstruction
4.
Preventive or prophylactic
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Diagnostic surgery
Obtaining tissue sample for
analysis of cells suspected to be

malignant.
2/1/15
This can be done through BIOPSY

Diagnostic surgery
The biopsy may be taken from the

actual tumour or from lymph nodes
near the suspicious tumour
2/1/15
Biopsy types
2/1/15
They include:
Incisional biopsy
Excisional biopsy
Needle biopsy
Endoscopic biopsy
Incisional Biopsy
small
portion of
tissue is
removed
and
examined
2/1/15
Excisional biopsy
The whole tumor is removed.
2/1/15
Needle biopsy
Needle is used
to aspirate
fluid or tissues
2/1/15
Endoscopic Biopsy
visualization of
potentially
cancerous lesions
2/1/15
Biopsy is taken
SURGERY AS PRIMARY METHOD OF

TREATMENT (CURATIVE)
2/1/15
1. Curative surgery
Aim
2/1/15
Removal of the tumor mass

and a safe margin of healthy
tissue around it.
APPROACHES TO CURATIVE SURGERY

1.
2.
Local excision
Often performed at OPD
Used if mass is small
Involves removal of mass and margin of
normal tissues
Wide/radical excision
2/1/15
Removal of lymph node, adjacent

involved structures and surrounding
involved structures
2. Prophylactic surgery
This is done to prevent the

development of cancer in people who
have high risk of developing cancer.
This may be due to family history and

genetic predisposition e.g. positive
BRAC1 or BRAC2 findings
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3. PALLIATIVE SURGERY
This is done when cure is not possible
The surgery is performed to make

patient as comfortable as possible
and promote quality of life.
The surgery relieve complications of

cancer such as ulcerations and pain.
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4. RECONSTRUCTIVE
SURGERY
This normally follows curative or

radical surgery
Aim:
To improve function or obtain a

desirable cosmetic effect
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5.Ablative surgery
2/1/15
This may be undertaken to remove

hormonal influences on tumour
growth through procedures such as
oophorectomy, adrenalectomy
and orchidectomy
6. ADJUVANT THERAPY
Used to remove residual mass in

radio or chemo-sensitive tumors
2/1/15
Nursing management in cancer

surgery
1.
Pre-operative assessment
2/1/15
Assess factors that may affect the

patient undergoing the surgical
procedure
Nursing Management
contd
Relieving anxiety
Give patient and family adequate

time to discuss possible changes and
outcomes
2/1/15
Provide necessary information
CHEMOTHERAPY
The word chemotherapy comes from two

words, chemical and therapy
It literally means the use of chemicals to

treat disease.
In recent times, the term is most frequently

used in reference to the treatment of
cancer.
Hence the names
cytotoxic
compiled by
Isaac Amankwaa agents or cell
2/1/15
CHEMOTHERAPY-CONTD
Goal of chemotherapy
To reduce the number of cells to a small

number that can be handled by the
immune system
Indication
primary or secondary tumors that are

disseminated through the body
2/1/15
Role of Chemotherapy
1.
Salvage chemotherapy: used when

patient have relapsed after being treated
with another modality.
2.
Adjuvant chemotherapy: used after the

removal of the primary tumor to destroy
any micro metastatic disease.
2/1/15
Role of Chemotherapy
contd
3.
Neoadjuvant chemotherapy
4.
Palliative chemotherapy
2/1/15
debulking or reducing the size of tumor
use to improve the quality of life of patient.
Mechanism of action
The cell cycle
2/1/15
2/1/15
Mechanism of action
They sustain their major cytotoxic

effects during a particular phase of
the life cycle
Actively dividing cells: the most
sensitive to chemotherapy
Non-dividing cells: least sensitive
to cytotoxic drugs
Hence repeated doses of chemotherapy
needed to kill nondividing cells that are
about to divide
2/1/15
Classification of chemotherapeautic
agents
Chemotherapeautic agents can be

classified by:
2/1/15
The relationship to the cell cycle

Chemical group
Classification by relationship to the cell

cycle
Cell Cycle Specific Agents

Antimetabolites
Cell Cycle NonSpecific Agents
Bleomycin
Alkylating Agents
Podophyllin Alkaloids
Antibiotics
Plant Alkaloids
Cisplatin
Nitrosoureas
2/1/15
ALKYLATING AGENTS
2/1/15
Developed from the poison mustard

gases first used in WW1.
They alter DNA molecules structure
The defective DNA molecule is unable to
carry out normal cellular reproductive
functions
This results in inhibition of cell growth
and reproduction
Examples: busulfan and Cyclophosphamide
ANTIMETABOLITES
They resemble substances normally used

by cells in their growth or metabolism e.g.
folic acids.
Are mistakenly incorporated into cells;

antagonizing cellular processes.
Are cell specific; act only on rapidly

dividing cells.
E.g. Mercaptopurine,
Methotraxate
and
compiled by Isaac
Amankwaa
2/1/15
MITOTIC INHIBITORS
They block cell division during mitosis.
M phase of cell cycle
E.gs. vinblastine and vincristine and

Vinca alkaloids
2/1/15
ANTITUMOR METABOLITES
These interfere with DNA synthesis and RNA

transcription.
2/1/15
eg. Doxorubicin and Bleomycin
Antibiotics
These are antineoplastic agents derived

from microorganisms
The difference btnx this and antibiotics

used in treating infections is that
antineoplastic antibiotics lack selective
toxicity
2/1/15
Antibiotics
Mechanism of action
They interfere with one or more

stages of RNA or DNA synthesis or
both
2/1/15
They are cell cycle non-specific
Examples: Doxorubicin and Bleomycin

TOPOISOMERASE INHIBITORS
Inhibit the enzyme topoisomerase

which is essential for the
maintenance of the DNA replication
2/1/15
E.g Irinotecan and Topotecan
HORMONE THERAPY
Hormones are capable of selectively

suppressing the growth of certain tissues of
the body without exerting cytotoxic effects
For example, estrogen can be employed to

alter the hormonal environment of the
tissues dependent on them
2/1/15
Eg Tamoxifen and Raloxefen

Biological-response
modifiers
They work by targeting and

enhancing the immune system
The persons own immune system

is activated to fight cancer cells
2/1/15
Examples include: interferons

Chemotherapy - strategy
single drug used rarely

combination
2/1/15
provides maximal cell kill within

tolerable toxicity
provides broader range of coverage of
resistant cells in a heterogeneous
tumor
prevents/slows the development of
resistant cells
Chemotherapy routes of
administration
oral
intrapericardial
intravenous
intraarterial
intramuscular
intrathecal
isolated organ
perfusion
intraperitoneal
portal vein
intrapleural
limb
2/1/15
Toxicities associated with

chemotherapy
Cytotoxic chemotherapys general mechanism

of action is to preferentially kill dividing cells.
Normal cells with rapid growth rate are very

susceptible to damage
Cells that have highly susceptible to toxicities

are Hair follicles, GI tract, Oral mucosa,
Germ cells and Bone marrow
2/1/15
Examples of toxicities
myelosuppression
immunosuppression
nausea/vomiting
alopecia
mucositis
diarrhea
flu-like
2/1/15
symptoms
ALOPECIA
Hair loss is a relatively common side effect of
chemotherapy.
It is one of the most often feared and
psychologically damaging consequences of
chemotherapy.
It most commonly affects scalp hair, but can
affect eyebrows, axillary, and pubic hair as
well.
It is often self-limited and transient, with hair
returning after cessation of therapy.
Often, the new hair has different color or
texture compiled by Isaac Amankwaa
2/1/15
ALOPECIA
2/1/15
It is important to discuss alopecia

when initiating a chemotherapy
regimen, especially one that is
very likely to cause it.
Setting the expectation can
decrease the anxiety associated
with the condition, and give the
patient time to prepare an
alternative strategy.
Bone Marrow suppression
2/1/15
One of the most common toxicities in

patients receiving chemo.
Particularly prevalent in patients receiving
chemo for hematologic malignancies.
This results in decreased production of
WBCs (leukopenia), granulocytes
(neutropenia), RBCs (anemia) and platelets
(thrombocytopenia)
This leads to increased risk of infection and
bleeding
Infertility
2/1/15
Testicular and ovarian function can be

affected by chemotherapeutic agents
Men may have azoospermia (absence of
spermatozoa).
Prevention of infertility
Sperm banking and cryopreservation
If no viable sperm or unable to produce

specimen, can perform testicular biopsy to
harvest directly from semineferous tubules.
Patients and their partners must be

informed of the abt the potential changes
in reproductive system
2/1/15
GIT effects
1.
Nausea and Vomiting
2/1/15
The most common side effect

Antiemetics can be used to control this
Nonpharmacologic approaches: imagery
and relaxation techniques
Small frequent meals and bland foods may
reduce the N and V.
GIT effects
The effect of chemotherapy on the

epithelium the GIT may lead to:
2/1/15
Stomatitis
Diarrhea
Renal system
Kidneys can be damage during excretion

and accumulation of end products of cell
lysis
This can be prevented by adequate

hydration, diuresis and alkalinization of
2/1/15
urine
Fatigue
This is a common side effect that

can last for months after treatment
2/1/15
Nursing management in
chemotherapy
Nursing diagnosis include:

1.
Risk for injury, infection related to bone

marrow suppression secondary to
chemotherapy
2.
Risk for bleeding related to bone marrow

suppression secondary to chemotherapy
3.
Impaired oral mucus membrane

(stomatitis) related to chemotherapy
2/1/15
Nursing management in
chemotherapy
Nursing diagnosis include:

4.
5.
6.
2/1/15
Impaired tissue integrity(alopecia) related

to chemotherapy
Imbalanced nutrition (less than body
requirement) related to nausea and
vomiting secondary to chemotherapy
Activity intolerance related to fatigue
secondary to chemotherapy
Radiation therapy
Objective
2/1/15
cure: as in thyroid carcinomas

Control malignant disease when
tumout cannot be removed surgically
Prophylactic: e.g. As in preventing
the spreading of primary tumour.
Radiation therapy
Mechanism of action
2/1/15
Ionizing radiation cause direct

alteration of the DNA molecule within
the cells of tissue
It breaks the strands of the DNA helix,
leading to cell death.
If the DNA cannot repair itself, the cell
may die immediately
Radiation therapy
Mechanism of action
2/1/15
Cells are most vulnerable to the

disruptive effects of radiation during
DNA synthesis and mitosis (early S,
G2 and M phases.
Body tissues that undergo frequent
divisions are most sensitive to
radiation therapy
This includes: bone marrow,
lymphatic
tisssue, GIT epithelial, hair
Mode of delivery
Teletherapy: external beam

radiation
Brachytherapy: internal delivery
Systemic
Contact or surface molds
2/1/15
Radiation Toxicities
1.
2.
3.
4.
5.
6.
2/1/15
Bone marrow suppression

Stomatitis /mucositis
Diarrhea
Fatigue
Alopecia
Constipation
Radiation toxicities
7.
8.
9.
10.
11.
12.
13.
2/1/15
Fatigue
Weight loss
Anorexia
Nausea and vomiting
Malaise
Ototoxicity
Teratogenic effect
Nursing care
1.
Assessment
1.
2.
2.
2/1/15
pts skin & oropharyngeal mucosa

Patients nutritional status
Explanation of adverse effects to

patients
Protecting caregivers
Pts receiving internal radiation emit

radiation while the implant is in place
Contact with healthcare team is therefore

guided by time, distance, and
shielding.
Radiation safety officer provides

information abt
2/1/15
maximum amount of time to be spent in pts

Protecting caregivers
2/1/15
Precautions for pts receiving brachytherapy

include:
Assigning patients to private rooms
Posting appropriate notices abt radiation
precautions
Staff wearing dosimeter badges
Not assigning pregnant women to pts room
Limiting visits to 30 mins
Visitors to maintain a 6-feet distance frm
the radiation source
Further reading
2/1/15
Bone marrow transplants

Gene therapy
Unproven or unconventional
therapies
References
Brunner & Suddarths Textbook of

Medical-Surgical Nursing (12th edition)
Bonita et al. Pharmacological Aspects

of Nursing Car (7th edition)
Watsons Clinical Nursing & Related

Sciences (7th Edition)
2/1/15

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Oncology

The Study of Tumours and

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

5. Anaplasia: cells that lack normal cellular

compiled by Isaac Amankwaa

A leading cause of death worldwide,

compiled by Isaac Amankwaa

The 10 leading cancer types

(American Cancer Society, 2005)

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

LOOK GOOD, they are probably going to

If cells LOOK BAD, they are probably going to

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

Physical agents e.g. tobacco and

Infectious agents e.g. hepatitis B,

compiled by Isaac Amankwaa

Naming Tumors: Benign

2. Fibroma- fibrous tumor

Epithelial lining -papilo

Sarcomas: mesenchymal tumor

Carcinomas: epithelial tumors

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

Characteristics of Normal Matured

compiled by Isaac Amankwaa

regulating signals, proliferate

infiltrate adjacent structures

compiled by Isaac Amankwaa

Genes Involved in cancer

If altered, may form oncogenes

compiled by Isaac Amankwaa

Genes Involved in cancer

compiled by Isaac Amankwaa

Genes Involved in cancer

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

1. Defective cellular proliferation

compiled by Isaac Amankwaa

B. Respond differently to the signals that regulate

Cancer cells therefore divide indiscriminately

compiled by Isaac Amankwaa

2. Defective cellular differentiation

compiled by Isaac Amankwaa

Tumor suppressor genes.

Mutations can turn these normal

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

Tumor development goes through 3

compiled by Isaac Amankwaa

Alteration of cells genetic

Altered cells may develop into a

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

The final stage of tumor

Increased growth rate of the tumor,

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa

compiled by Isaac Amankwaa