Prepared by: Anna Marie M.

Montalban, RN, US-RN

1. Description of cancer 2. Definition of terms: Apoptosis Benign Carcinogen Carcinoma Hospice Lymphomas Leukemia or myeloma Malignant Metastasis Nadir Neoplasm Sarcoma Tumor markers Undifferentiated cells

3.Classify cancer. 4. Pathophysiology of cancer cells/theory of pathogenesis 5. Grading and Staging and TNM CLASSIFICATION SYSTEM 6. Elaborate the seven warning signs of cancer . 7. Identify the risk factors. 8. Identify common tumor markers. 9. Identify diagnostic tests. 10. Differentiate benign from malignant neoplasms. 11. Differentiate proliferative patterns from characteristics of a normal cells.

DESCRIPTION: - A neoplasic disorder that can involve all body organs

characterized by: a. Uncontrolled growth and spread of abnormal cells b. Proliferation: rapid reproduction by cell division c. Invasion: growth of primary tumor into surrounding tissue d. Metastasis: spread or transfer of cancer cells from one organ or part to another not directly connected. - Result from a process of altered cell growth and differentiation which is uncoordinated and lacks normal regulatory controls over cell growth and division.

DEFINITION OF TERMS:
apoptosis: program & controlled cell destruction w/c eliminates damaged, improperly produced & worn out cells w/out harming the other areas. A normal process of cell deletion & renewal. carcinogen: a physical, chemical, or biological stressor that causes neoplastic changes in normal cells. carcinoma: a new growth or malignant tumor that originates from epithelial cells, the skin, GIT, lungs , uterus, breast and other organs. differentiation: a process which normal body cells have individual characteristics allowing them to perform different body functions. Hospice: a concept of care for terminally ill clients that includes the idea of intensive caring rather than intensive care. The family and the client are the focus of nursing care and the goal is to relieve pain and facilitate the optimal quality of life.

Lymphomas: neoplasms that originate from the lymphoid organs. Leukemia or myelomas: neoplasms that originates from blood forming organs. Malignant: term for growth that metastasize and grow; cancerous lesions that are disordered, uncontrolled and chaotic proliferation of cells. Metastasis: the transfer of disease from organ or part to another not directly connected w/it. Nadir: the period of time during w/c an antineoplastic med has its most profound effects on the B.M. Neoplasm: a new growth, w/c maybe benign or malignant. Protooncogenes: a normal gene that can become an oncogene d/t mutation or increased expression. Oncogene: a gene that has the potential to cause CA; protooncogenes which is converted via mutation/chromosomal arrangement.

Sarcomas: neoplasms that originate from muscle, bone, fat, lymph system, or connective tissues. Tumor markers: specific bodily subs. that seem to indicate tumor progression or regression. Undifferentiated cells: cells that have lost the capacity for specialized functions.

5 STAGES: 1.) Gap/Growth phase (G1) time after formation of cell, RNA, CHON synthesis 2.) Synthesis (S) phase DNA replication 3.) Gap/Growth phase (G2) continued RNA & CHON synthesis 4.) Mitosis: cell division: PMAT Prophase: chromatin coil shortens forming 2 pairs of chromatids, centrioles move to opposite end forming a mitotic spindle Metaphase: chromosomes cluster & align midway between spindle poles Anaphase: centromeres divide, divided chromosomes moves to opposite side of the spindle poles. Telophase: chromosome uncoil & become chromatin, nuclear envelope and nucleoli appear at each daughter cell 5.) Go cells not yet destined to replicate, ceases at this stage

a.

b.

c.

d.

Benign & malignant cells display diff. characteristics of cellular growth, degree of differentiation (anaplasia) that determines cells malignant potential. hyperplasia: increase in the number of cells in a tissue; maybe normal/abnormal cellular response. Metaplasia: refers to conversion of 1 type of cell in a tissue to another type not normal for that tissue it results from an outside stimulus affecting parent stem cells and maybe reversible or progress to dysplasia. Dysplasia: refers to change in size, shape or arrangement of normal cells into bizarre cells may precede an irreversible neoplastic change. Anaplasia: involves a change in the structure of cells & their orientation to one another, Cx by loss of differentiation returning to a more primitive form.

e. Neoplasia: refers to abnormal cell growth; maybe benign or malignant. Benign: harmless, not infiltrative of other tissues Malignant: always harmful, may spread or metastasize to tissues sometimes far removed from the site of origin. CHARACTERISITIC OF A PROLIFERATIVE CELL/TUMOR

NEOPLASTIC CELLS

NEOPLASTIC TUMORS

Appear larger than normal Disorganized, irregular w/ bigger nuclei nests or sheets or neoplastic cells Exhibit uncontrolled proliferation w/no contact inhibition. Serve no homeostatic function. Contain high % of proliferating cells Some have the ability to metastasize spread from the original site to

a.) Solid tumors: associated w/the organs from w/c they develop, e.g breast or lung CA. b.) Hematological CA: originates from blood cell forming tissues e.g. leukemia, lymphoma

RISK FACTORS:
-tobacco -alcohol -diet -reproductive and sexual behavior -occupation -pollution -industrial products -medicines -infectious agents -endogenous hormone -genetics

PATHOPHYSIOLOGY OF CANCER CELLS: CARCINOGENESIS Involves 3 process: 1. Initiation : carcinogens changes the DNA of the cell causing cell mutation 2. Promotion: repeated exposure to carcinogen resulting to expression of cellular abnormality or genetic mutation 3. Progression: the expressed ability to invade and metastasize.

Cell alteration mutation of protooncogene inactivate tumor (activate cell proliferation suppressing gene & differentiation)

Activate oncogene cell lose control/differentiation

unregulated cell growth malignant neoplasm Epithelial lining of the Mammary ducts/lobules E.L. of the (breast CA) major bronchi (lung CA) Hematopoietic stem cells (Leukemia)

Theory of Pathogenesis 1. Transform by unknown mechanism on exposure to certain etiologic agents including: Virus: (EBV, HSV II, HPV,CMV,Hepa B) - oncovirus Chemical: cobalt, tar, asphalt, aniline dyes, hydrocarbons in cigarette smoke, air pollutants from industry, fuel oils Physical stressors: excessive exposure to sunlight or radiation, diet: high fat & low fiber diets, high animal fat intake, preservatives, additives, nitrates Genetic: abnormal chromosome patterns Burkitts lymphoma, AML/CML, skin CA or familial predispositions e.g breast, colorectal, stomach & lung CA 2. Devt of CA is often closely linked to immune system failure as evidenced by: -increased incidence of malignancy in organ transplant recipients who receive immunosuppressive therapy.

Increased risk for devt of 2nd malignancies in pt receiving long term chemo to treat 1st malignancy. 3. CA occurrence typically reflects a combination of genetic inheritance, host mechanism, and envtl influences contribute 80-90% of all CA.
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Predisposing factors

Precipitating factors

CA begins at molecular stage, begins mutation & damage of 1 or more genomes. Abnormal cells forms a clone & begins to proliferate abnormally.

Abnormal cells infiltrate to tissues, gain access to lymph & blood vessels causing an access to other areas in the body.

GRADING AND STAGING GRADING:

Grade I: Cells differ slightly from normal cells and are well differentiated (mild dysplasia). Grade II: cells are more abnormal and are moderately differentiated(moderate dysplasia). Grade III: cells are very abnormal and are poorly differentiated (severe dysplasia) Grade IV: cells are immature (anaplasia) & undifferentiated

STAGING

Stage 0: carcinoma in situ Stage I: tumor limited to the tissue of origin, localized tumor growth (in primary site but has not spread) Stage II: Limited local spread (spread to nearby area but still in primary site) Stage III: Extensive local and regional spread (spread throughout nearby area) Stage IV: Metastasis (spread to close or distant organs) COMMON SITES OF METASTASIS BREAST CA: bone, lung LUNG CA: brain COLORECTAL CA: liver PROSTATE CA: bone, spine BRAIN TUMORS: CNS

TNM CLASSIFICATION SYSTEM Green, F., et al. 6th edition. AJCC Cancer Staging Manual
SYMBOL T N M INTERPRETATION The extent of the primary tumor The absence or presence and extent of regional lymph node metastasis The absence or presence of distant metastasis THE USE OF NUMERICAL SUBSETS OF TNM COMPONENTS INDICATES THE PROGRESSIVE EXTENT OF THE MALIGNANT DISEASE. T N M PRIMARY TUMOR REGIONAL LYMPH NODE DISTANT METASTASIS

PRIMARY TUMOR (T) Tx T0 Tis T1, T2, T3, T4 Primary tumor cannot be assessed. No evidence of primary tumor. Carcinoma in Situ Increasing size and/or local extent of the primary tumor

REGIONAL LYMPH NODES (N) Nx N0 N1, N2, N3 Regional Lymph nodes cannot be assessed. No regional lymph node metastasis. Increasing involvement of regional lymph nodes

DISTANT METASTASIS (M) Mx M0 M1 Distant metastasis cannot be assessed. No distant metastasis Distant metastasis

C A U T I O N UP
C hange in bowel/bladder habits A ny sore that does not heal U nusual bleeding or discharge T hickening or lump in breast or elsewhere I ndigestion O bvious change in wart or mole N agging cough or hoarseness U nusual anemia P - ain

Benign and Malignant cells DIFFERS in:

Cellular growth characteristics Method of growth Rate of growth Ability to metastasize or spread General effects Destruction of tissue Ability to cause death

Difference Between Benign and malignant

BENIGN
Cell characteristics

MALIGNANT Cells are undifferentiated Often bear little resemblance to the normal cells of the tissue from which they arise

Well- differentiated cells that resemble normal cells of the tissue from which the tumor originated

Mode of growth Tumor grows by

Grows at the expansion and does periphery and sends not infiltrate the out processes that surrounding tissues; infiltrate and destroy usually the surrounding encapsulated tissues

BENIGN

MALIGNANT

Rate of growth slow

Variable; depends on level of differentiation (the more anaplastic the tumor the faster its growth Gains access to the blood and lymphatic channels and metastasize to other areas of the body MALIGNANT
Often causes generalized effects, such as anemia, weakness, and wt. loss

Metastasis

Does not spread by metastasis

BENIGN
General effects Usually localized phenomenon that does not cause generalized effects unless its location interferes with vital functions

BENIGN
Tissue destruction Does not usually cause tissue damage unless its location interferes with blood flow

MALIGNANT
Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage

Ability to cause Does not usually death cause death unless its location interferes with vital functions

Usually causes death unless growth can be controlled

Tissue of origin
Adeno glandular tissue (with glands) Angio blood vessels(arteries, veins, capillaries) Basal cell epithelium,mainly sun exposed areas embryonal gonads fibro fibrous tissue (ligaments & tendons) lympho lymphoid tissue (tonsils, peyers,lymph nodes Melano pigmented cells of epithelium Myo muscle tissue (heart) osteo bone squamous epithelium cell

Cellular origin
Oligodendroglioma dendrites Meningioma meninges Medulloblastoma medulla Epindydomas - ependymal cells Astrocytoma - astrocytes

MARKER

CLINICAL SIGNIFICANCE

Alpha fetoprotein (AFP)

Carcinoembryonic antigen (CEA) Prostate specific antigen (PSA)

Testicle cancer
Colon cancer Prostate cancer

CA 15-3
CA 125 HCG

Breast cancer
Ovarian cancer Gestational trophoblastic disease

General Cancer Signs And Symptoms

1. Weight loss 2. Fever 3. Fatigue 4. Pain 5. Changes in skin

Specific Cancer Signs and Symptoms

1. Changes in bowel habits and bladder fnx 2. Sores that do not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or other parts of the body 5. Ingestion or trouble swallowing 6. Recent change in wart or mole 7. Nagging cough or hoarseness

DETECTION and PREVENTION of CANCER

PRIMARY PREVENTION
1. Acquisition of knowledge and skills to educate client, community and society about cancer risk 2. Assisting patients to avoid known carcinogenic substances 3. Involvement in the adopting dietary and various lifestyle changes 4. Use of teaching and counseling skills to encourage patients to participate in cancer prevention programs and promotion of healthy lifestyles

SECONDARY PREVENTION
1. Cancer screening programs

PREVENTION OF CANCER
Smoking damages nearly every organ in the human body, is linked to at least 10 different cancers, and accounts for some 30% of all cancer deaths Quit smoking! A sunburn will fade, but damage to deeper layers of skin

Finding a shade, wearing hats, sunglasses, and clothingare needed to shield your skin from the sun. Sunscreen alone is not enough protection. Eating right, being active, and maintaining a healthy weight are important ways to reduce your risk of canceras well as heart disease and diabetes

Control food portions for a great start for weight loss. Use low-fat cooking methods like roasting, baking, broiling, steaming, or poaching. Choose foods that are rich in anti-oxidants. Minimal amount of oil please

Find activities to fit your lifestyle and ideas for raising active kids as well as staying motivated yourself. Incorporate fitness into your lifestyle. Motivate yourself.

a.) Early detection: SCREENING TEST 7 early warning signs of cancer: C A U T I O N UP BSE: perform 7-10 days after menses; postmenopausal /hysterectomy clients should select specific day of the month. TSE: Papanicolaous test (Pap) smear test: cytologic analysis of a sample scrape from the cervix & other tissues cervical neoplasia. Stools for occult blood guiac test Sigmoidoscopy ( using flexible scope to examine the rectum & sigmoid colon), colonoscopy (fiberoptic endoscopy study in the
lining of the large intestine).
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Mammography

b.) Primary prevention: b.1) focuses on reducing risk factors external/internal environment that increases the susceptibility of the pt for CA devt. b.2) General factors that influences CA incidence & mortality: -sex, age, geographic location, socioeconomic status -ethnic/cultural background, personal habits, occupation and personal/family health histories.

BREAST SELF EXAMINATION

- Cervical CA: early age @ 1st intercourse, multiple sexual partners, HPV infection (condyloma/warts),smoking

DIAGNOSTIC EXAMS

Laboratory exams
1. Blood and urine tests

2. Alkaline phosphates - increase in osteogenic carcinoma

3. Calcium - elevated in multiple myeloma bone metastases 4. Sodium - decreased in bronchogenic carcinoma 5. Potassium - decreased in extensive liver carcinoma 6. Serum Gastrin - measures gastric secretions 7. Neutrophilic leukocytosis tumors 8. Eosinophilic leukocytosis brain tumors, Hodgkins disease 9. Lymocytosis chronic lymphocytotic anemia

Biopsy: surgical incision of a small piece of tissue for microscopic examination, provides histological proof of malignancy. Types: needle: aspiration of cells Incisional: removal of a wedge of suspected tissue from a larger mass Exicisional: complete removal of the entire lesion Staging: multiple needle or incisional biopsies in tissues where metastasis is suspected. Tissue Examination: Following excision: frozen section or permanent paraffin section. FROZEN SECTION: quick, takes minutes diagnosis (+) PARAFFIN SECTION: takes about 24 hours clearer details
1.

Interventions: OPD setting prepare pt w/docs order obtain Inform consent. 2. BMA if hematolymphoid malignancy is suspected. 3. Chest radiograph 4. CBC 5. CT scan: computed tomography 6. Cytological studies: Pap smear 7. Liver function test: ALT/AST 8. MRI 9. Presence of oncofetal Ag such as CEA & AFP 10. Protoscopic examination: Guaiac for occult blood 11. Radiographic studies: mammogram 12. Radioisotope scans: liver, brain, bone, lung

Magnetic Resonance Imaging (MRI) scan

PREVENTION OF CANCER USING ANTI-OXIDANTS

Antioxidants
substances that may protect cells from the damage caused by unstable molecules known as free radicals.

1. Beta-carotene sweet potatoes carrots cantaloupe squash apricots pumpkin mangos

Some green leafy vegetables like:

collard greens spinach kale

2. Lutein
for healthy eyes is found in green leafy vegetables such as:

collard greens Spinach kale 3. Lycopene Tomatoes watermelon guava papaya apricots pink grapefruit blood

4. Selenium ( mineral) a component of antioxidant enzymes. Plant foods like: rice & wheat Brazil nuts contain selenium. 5. Vitamin A Liver sweet potatoes Carrots Milk egg yolks mozzarella cheese.

6. Vitamin C (ascorbic acid) fruits and vegetables Cereals Beef poultry and fish. 7. Vitamin E (alpha-tocopherol) in many oils including: wheat germ Safflower corn and soybean oils also found in: Mangos, Nuts, & broccoli

a.) Prophylactic surgery: perform w/existing premalignant condition or known family hx predisposing the person to CA devt. b.) Curative surgery: all gross & microscopic tumor is removed or destroyed. c.) control (cytoreductive): a debulking procedure consist of removing part of the tumor thus decreasing the number of CA cells, increasing the chance of other therapies. d.) Palliative: improve quality of life during survival time; Done to reduce pain, relieve airway, GIT or urinary tract obstruction; relieve pressure on the brain or spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscess. e.) reconstructive or rehabilitative: improve quality of life by restoring maximal fxn & appearance.

S/E of surgery: 1. Loss of function of a specific body part 2. Reduced function as a result of organ loss 3. Scarring or disfigurement 4. Grieving about altered body image or imposed change in lifestyle.

Assignment: Saturday. June 18, 2011

Read on radiation therapy, bone marrow transplantation. Quiz on the discussed topics.

Magnetic Resonance Imaging (MRI) scan

Cellular origin
Oligodendroglioma dendrites Meningioma meninges

Medulloblastoma medulla
Epindydomas - ependymal cells

Astrocytoma - astrocytes