Unit 5

UNIT 5 INTRODUCTION TO ONCOLOGY
NURSING
Structure
5.0 Objectives
5.1 Introduction
5.2 Basic Concepts of Cancer (Malignancy)
5.2.1 Epidemiology of Cancer
5.2.2 Characteristics of Malignant Cell
5.2.3 General Classification of Neoplasms
5.2.4 Etiological Factors
5.2.5 Signs and Symptoms
5.2.6 Staging and Grading of Malignant Tumors
5.3 Common Diagnostic Measures for Cancer
5.4 Prevention and Control of Cancer
5.5 Treatment Modalities
5.5.1 Surgery
5.5.2 Radiation
5.5.3 Chemotherapy
5.5.4 Biotherapy
5.5.5 Bone Marrow Transplantation
5.6 Oncology Emergencies and Nursing ~nterventions
5.7 Rehabilitation of Cancer Patients
5.8 Palliative Care
5.8.1 Concept of Palliative Care
5.8.2 Elements of Palliative Care
5.8.3 Comfort in Palliative Care
5.8.4 Barriers to Delivering Palliative Care
5.8.5 Symptom Control and Pain Management
5.9 Let Us Sum Up
5.10 Key Words
5.11 Answers to Check Your Progress
5.0 OBJECTIVES
After completing this unit, you should be able to:
describe the characteristics of malignant cells;
differentiate between benign and malignant tumours;
.e list down the warning signs of cancer;

a describe the common methods for diagnosis of cancer;
%tusculoskeletal,Gastrointestinal enumerate the etiological factors of cancer;
and Oncoiogy Nursing
identify the staging and grading of Tumors; and
identifl the preventive, curative and rehabilitative measures.
5.1 INTRODUCTION
In Unit 4, you have learnt about the diseases of gastrointestinal system, which
also included the discussion on cancers of gastrointestinal system. Oncology is the
study of tumours. Neoplasia means abnormal new growth, which may be benign
or malignant. Cancer is a term that is used to describe a wide variety of
malignant diseases, the management of which required several medical disciplines
such as preventive approach, radiotherapy, chemotherapy, harmonetherapy and
surgical intervention.
All cancers are the result of the uncontrolled overproduction of some particular
cells. Normally, worn out cells are replaced by a process of cell division. But if
cells are produced in excess of what is needed for replacement, there occurs a
buildup of tissue. When this forms a mass or tumour, it may cause symptoms
such as swelling, obstruction and pain. In order to understand this you need to
learn the basic concepts such as:
What is cancer cell?
How does it differ from a normal cell?
What are the factors that cause cancer cells to develop?
What are the preventive and control measures and the methods of early
detection? and
What are the common diagnostic procedures?
In this unit, the focus call be on the basic concept of cancer. The discussion will
be about the benign and malignant turno~rs,~their characteristics, classification,
etiology and signs and symptoms. The caring of cancer patients is a challenging
task for you as a nurse and your main role is to prevent, detect or rehabilitate
people with cancer.
One of the major roles of nurse is to take care of patient with cancer before,
during and after diagnostic procedures and therapies. We shall focus on diagnostic
procedures and nursing intervention.
Finally, the discussion will be on the staging and grading of tumors and the
prevention and control of rehabilitative measures of cancer.
Let us begin with the basic concepts of cancer.
5.2 BASIC CONCEPTS OF CANCER

(MALIGNANCY)
The sign of the Zodiac Cancer is the crab. A crab as you know moves fast in all
directions. Similarly, the disease cancer also spreads in all directions. Hence the
name cancer remains with this disease.
Cancer occurs in all strata of our society. It affects rich and poor with equally
devastating effects. It strikes people of all ages, sexes and socio-economic and
I ;1 cultural backgrounds. But certain cancers are particularly associated with certain
age groups and areas; some occur most frequently in children, some in old people Introduction to
Oncology Nursing
and others are more commonly found in the developed countries that the
underdeveloped. The largest number of malignant tumours occur in four areas of
the body: the lungs, Colon-rectum, breasts, and the prostate. Cancer is one of the
major causes of death and also one of the most vigorously researched and
aggressively treated illness of our time. Most people until recently believed that
cancer was incurable. But research and technology along with advances in
diagnosis and treatment have helped cure cancer in many cases. It must be
realized that although all cancer patients cannot be cured, all can be helped. It is
not a contagious disease, there is no stigma attached to having cancer and these
are no known home remedies, patent medicines or ointments that will cure it.
'
The word "cancer" abbreviated "Ca" is synonymous with the term malignant
neoplasm.
Other words connoting malignant neoplasm include tumour, malignancy carcinoma
and aberrant cellular growth. However these terms are not interchangeable. Now
we can more precisely say that cancer is a malignant neoplasm, a harmful tumour
resulting from uncontrolled growth of the tissues. We shall now briefly elaborate
on these terms.
The word neoplasm is derived fkom the Greek neos, which means and plasia
means growth of new tissues. It can be either benign or malignant. A neoplasm is
a new growth of abnomlal tissue, which serves no purpose and which may harm
the host organism.
A benign neoplasm or tumour is usually harmless and does not infiltrate other
tissues, whereas a malignant neoplasm is always harmhl and may spread or
metastasize to other tissues far from the site of origin.
Strictly defined, a "tumour" is any abnormal swelling or enlargement. It is one of
the four signs of inflammation - redness, heat, swelling or tumour and pain. Thus
even though the proliferation of neoplastic cells results in a tumour, tumourous
swellings are not always neoplastic. Nevertheless, "tumour" is often used to
denote a malignant neoplasm while the word "malignant" (threatening to life)
usually is applied to neoplasms. It also describes other conditions, for example
malignant hypertension.
Carcinoma is a specific form of cancer derived from epithelial cells.
Aberrant cellular growth can refer to any abnormal cellular growth. It may or may
not give rise to cancer. Basically, cancer is a disease of the cell in which the
normal mechanisms of control of growth and proliferation are disturbed. Cancer is
also used as a collective term describing a large group of diseases characterized
by uncontrolled growth and spread of abnormal cells. These tissues arise in
different tissues and organs, differ greatly from one another in appearance and
growth habits may follow different course of development in their hosts and
respond differently to intervention. With this concept, in mind, we shall now
discuss about the characteristics of cancer cells, classification of neoplasms,
etiology and signs and sj~mptomsin the following, sub-sections.
5.2.1 Epidemiology of Cancer

It is not possible to estimate precisely the actual number of cancer patients in the
country, The Indian Council of Medical research initiated a National Cancer
Registry Program in 1981- 1982 by augmenting the population based cancer
registry at Bombay and setting up two more population based cancer registries at
Banglore and Chennai and three hospital based cancer registries were subsequently
set up at Delhi, Bhopal, and Barshi. Total population covered by these registries is
about 3.5%.
Musculoskeletal Gastrointestinal Estimates from the various National Cancer Registry program reports, and based
and Oncology Nursing
on extrapolation to account for the new population landmark of 1 Billion, the
estimated number of new cases in India is about 10,00,000 per year. The most
common form of cancers seen in the males include cancer of the lung, stomach,
esophagus, mouth, larynx, hypopharynx, tongue, prostate, ui-inary bladder, and
rectum. In the females the most common cancers are cancers of the cervix, uterus,
breast, mouth, esophagus, ovary, hypopharynx, thyroid, colon, rectum, gall bladder
and body uterus.
In males, lung cancer seems to be the major cause of mortality from cancer, and this
has an upward spiral. In females, traditional cancer of the cervix was the leading
cancer, but of late, especially in the urban areas, cancer of the breast seems to be,
becoming a major problem. Cancers of the mouth are commonly seen in both the
males and the females. Cancers of the larynx, hypopharynx, esophagus and stomach
are seen more in the men as compared to females, while cancer of the gall- bladder
is seen more often in women. There has been in the patterns of cancers seen in
various parts of the country, as has been brought out in the different population
based cancer registries.
It would be pertinent to point out that about one third of the cancers seen in India
are tobacco related which has been directly implicated in the causation of the
cancers of the lungs, larynx, mouth and esophagus.
5.2.2 Characteristics of Malignant Cell

a Cancer cells are able to divide and multiply but not in a normal manner
a Cancer cells (neoplastic cells) differ from normal cells in appearance, patterns
of growth and physiologic function. They are usually larger than normal cells
and they have a bigger nucleus
a They differ in size and shape while normal cells are more homogenous
a They develop antigens that are completely different from a normal cell
a Neoplastic cells exist a parasites, occupying space and drawing nutrition and
sustenance from the host's body while contributing nothing in return
a Instead of limiting their growth to meet the specific needs of the body, they
continue to reproduce in a disorderly and unrestricted manner
a Malignant tumours are capable of continued growth that will compress,

invade and destroy normal tissue. These cells break away from their original
sites and are transported by the bloodllymph to new sites where they begin
to grow, and that is called metastasis.
5.2.3 General Classification of Neoplasms

Neoplastic turnours are classified as either benign or malignant and are also
classified according to the tissue from which they originate.
Benign and Malignant Tumours

Benign tumours are defined as localized growth of cells that are very closely
related to normal cells except for their abnormal arrangement and amount. If the
tumour is located near a vital tube or organ, it could be fatal, persons with benign
tumour have good prognosis as the tumour can be safely excised.
Malignant tumours on the other hand may be defined as progressive autonomous Introduction to
Oncology Nursing
proliferation of tissue not subject to the laws of governing orderly growth. These
tumours represent a serious threaf to the life and well being of the host.
Classification According to Tissue of Origin

As you have noted that tumours are also classified according to the tissue of their
origin. Study the Table 5.1 you will note that almost all names for tumours end .in
the suffix "Oma", meaning "tumour". This suffix is usually attached to the term
of a parent tissue of the tumo&. Thus we can say that adenoma comes from
Greek 'aden' which means 'gland' and 'Oma' for 'tumour'. When the neoplasm is
formed of more than one parent tissue, then the name of turnour represents both
the tissue. For example, an adenomyoma is benign neoplasm that contains both
glandular and muscle cells. Because epithelial tissues vary greatly, benign txmours
of epithelial origin are classified according to either their microscopic appearance
(e.g., adenoma) or their macroscopic appearance (e.g., polyp).
Musculoskeletal, Gastrointestinal AS you study Table 5.1, note that the fibroma, lipoma and leiomyoma are the
most common benign tumour.
Fibroma may grown anywhere in the body most often in the uterus. They are
gznerally small, but occasionally grown to a great size. These encapsulated
harmless tumours do not cause symptoms unless they press on a bone or nerve.
They can be removed surgically.
Lipoma arises in adipose tissue. They rarely cause symptoms but are poorly
encapsulated and may press on surrounding tissues as they expand.
Leiomyoma is a benign neoplasm of smooth muscle origin and is the most
common benign tumour in women. They may develop anywhere in the body, but
most commonly in the uterus.
Let us now consider the most prevalent malignant type of neoplasms.
Carcinoma is used for cancer of the epithelial tissues such' as skin or stomach
lining.
Sarcoma is cancer of the bone, connective tissue e.g. blood vessels, lymphatic
nerve tissue, muscles and cartilages. '
Leukaemias are related to the abnormal uncontrolled multiplication of while
blood cells.
Lymphomas are found in lymph nodes of the organs and are characterized by
overproduction of cells in the organ.
You may be knowing about the three representative examples of malignant
neoplasm which include carcinoma in skin, fibrosarcoma, and bronchogenic
carcinoma. We shall briefly review each of these malignant neoplasm.
Carcinoma in situ is neoplasm of epithelial tissues that remains confined to the
site of origin. Carcinoma in situ typically affects the cervix, and it may occur in
squamous epithelium in other parts of the body. This form of cancer can be
removed surgically because it is localized. However, you should remember that in
situ carcinoma can become invasive, eroding into surrounding tissues.
The malignant fibrosarcomas are similar to benign fibromas. They may originate
as benign fibromas, later becoming malignant. but these fibrosarcomas rarely
metastasize and respond to surgery.
Bronchogenic carcinoma usually develops in the lower trachea and lower bronchi
and very common form of cancer. This can be excised surgically but if it
metastasizes the surgery is contraindicated.
5.2.4 Etiological Factors

Although the specific cause of cancer is unknown, researchers suspect that cancer
is frequently caused by multiple agents acting together. Agents that can cause
malignant changes in healthy cells after prolonged exposure are referred to as
carcinogenic agents or carcinogens. They are (i) viruses, (ii) chemical agents,
(iii) physical agents, (iv) hormones, (v) genetic factors, and (vi) dietary agents.
L& us elaborate each agent.
Viruses
Virus interrupt normal metabolic processes within the cell. Onc~ogenies,small
segments of genetic DNA when incorporated with a virus, have the potential of
causing cancer e.g., Hepes sufliea virus and human papilloma virus.
Chemical Agents Introduction to
0 1 1 c o l oNursing
~
Chemical agents include hydrocarbons. such as in cigarette smoke, air pollutants,
tar, soot, aniline dyes, asbestos, cobalt, chromium, nickel and arsenjc comnpoiunds.
Vinyl chloride, used in plastic industry, has been identitied as a carcinogeiiic agent
recently.
Physical Agents
Physical agents include ionizing radiation from gamma rays. X-rays, radioactive
isotopes, sunlight and ultraviolet radiation. Exposnre to ionizing radiation causes
an increased incidence of leukaemia. Sunlight and ultraviolet radiation may cause
skin cancers in people who undergo prolonged exposure to strong sunlight over a
substantial period of time. Physical traunla such as with Hot coal, ~nechanical
blows, or chronic irritations are often associated with cancer. Bladder stones,
chronic infcctions and parasitic infestations, causing chronic inflammatory
conditions, can also predispose a person to cancer.
Hormones
Hormones have been associated in the development of some forms of cancer.
Tumour growth and development appears to be related to horrnone secretion in
certain instances like breast cancer, prostrate cancer. For example, administration
of diethyl stilbestol (DES) during pregnancy has been related to development of
vaginal carcinoma in fernale children.
Genetic Predisposition
Certain cancers tend to run in i'amilies, for example, retinoblastoma, cancer of the
eye. Breast cancer occurs in first degree female relatives (sister, daughter) of
women with the disease approximately twice as frequently as the average for the
female population.
5.2.5 Signs and Symptoms

Cancer is insidioirs in onset and may often bc far advanced before the individual
experiences any symptoms. However, there are seven warning signs, recognized
worldwide, which should never be ignored or glossed over. These warning signs
are represented a CAUTION and you need 'to reinember it.
C : Change in bowel or bladder habits
A : A sore that does not hcal
U : Unusual bleeding or discharge
T : Thickening or lump in breast or elsewhere
I : Indigestion or difficulty in swallowing
O : Obvious change in a wart or mole
N : Uagging cough or hoarseness
Other s>~nptomswhich should be taken seriously especially when acco~npanying
Any of those just mentioned above are:

0 Weight loss not due to any change in diet or else due to unexplained loss of
appetite
0 In exceptional cases, pain, when it is persistent
Undue lassitude or inalaise
5.2.6 Staging and Grading of Malignant Turnors

When a neoplastic growth is definitely diagnosed, ~t must be further defined in
terms of its extent. This diagnostic process, called smging, ~nvolvesa systematic
search for (a) the characteristics of the primary turnour (using clinical exam~nation
and pathologic examination), (b) involvcmcnt of the lymph nodes (using clinical
M~~sculoskelelal,
Gastroin cxa~nination.lynnphangiography. and perhaps needle biopsy), and (c) evidetice of
and Oncology Kursing
inetas~asis,based on knowledge of thc 11aturz1 history of the disease.
The purpose of staging a cancer is to determine the bodily location of the cancer
and the degree to which spread has occurred The stllaller the tumor at the rime of
diaposis, greater the potenhal for cure or control. Therefus to decide the amount
and duration of treatment given for a specific malignancy, stage of that
rnaligna~zcy,the stage of that cancer must be detennined.
Methods Used for Staging
1) Clinical Staging: In this the size of the tumor (i;l cms.) and degree of
metastasis ( l ~ ynumber of sites) are determined by clinics! tests and
n~easureinentsuch as biopsy, but do riot include maillor surgery.
2) Surgical Staging: It reports the size of a tumor, the number of sites and the
degree of metastasis by appearance at surgery.
3) Pathological Staging: T~unorsize, number of sites. and degree of metastasis

are deterniinec: by pathologicai examination of tlssue obtained at surgery. It
provides the inforrnat~onabout cellular characteristics of the rumor.
4) TNM Systern of Staging: The TN!M system is the most common type of
sybtem for stag~ilgi~: usc today. "T" stands for tumour. "TI-14" defines the
increasing extent of the tumour size, "N" is for the regional lytnph nodes,
"Kl-N3" indicates advancing nodal disease, "MO" is for no metastasis, and
"MI"indicates that inelastasis is preserit. Table 5.2 summari~esthc TNM
staging system.
I
I
I
Tumour
TO / No evidence of primary turnour
II
/ T!S / Carcinoma in s ~ t u I
I
1 TI T2 T3 T4 1 Progressive increase in tumour size and involvement I
/L TX
--
I Nodes
-I--- I
Turnour cannot be assessed
A
i
/ Regional lymph nodes nor demonstrably abnormal !
I
I, Increasing degrees of demonstrable abnormality of regional

lymph nodes.
/ NX lymph nodes cannot be assessed clinicaliy
__1
i
[NISastasis I
,II No evidence of distant metastasis
( MI M2 M3 1 Ascending degrees of d~stantmetastasis, including I
i
L-- 1 metastasis to--
distant lymph nodes. -A
Check Your Progress I
1) List three characteristics of cancer ceils:

Introdoction to
Oncology Nursing
2) Differentiate between benign and malignant tumours.
................................................................................................................................
3) Fill in the blanks:
a) The benign tumour of fibrous tissue is ..............................
b) A benign tumour arising from the adipose tissue is called .................
c) The benign neoplasm of smooth muscle is ..............................
d) The malignant tumour of the bone is called ..............................
e) The abnormal uncontrolled multiplication of white blood cells is called

..................
f) The malignant transfornation of lyrnph node is .......................................
4) List the etiological factors of cancer.
................................................................................................................................
5) List the seven warning signs of cancer:
\l~asculoshcletal, <;artrointestinal
and Oncology Norsing 6) Explain what does T2N IMO indicates.
5.3 COMMON DIAGNOSTIC MEASURES FOR

CANCER
'The general technique to detect cancer includes obtaining the person's familial and
environmental histories, performing thorough physical examination and doing
laboratory tests of blood and urine. How, here we mil! discuss the more
spcciali7ed techniques used for cancer detection and the nursing intervention in
these techniques.
1) Cytologic Examination or Papanicolaou Test (Pap Smear)

The Papanicolaou test was developed by George N. Papanicolaou in 1943. The
test is used to discuss primarily cancer of the cervix in the early stage and also
early cancers of the digestive, respiratory, renal tracts and occasionally of breasts.
Specimens that can be examined by Pap smear include (i) cervicai scrapping,
(ii) bronchial secretions and washings obtained by bronchoscopy, (iii) urine
sediment. (iv) coughed up sputum (v) aspirated gastric secretions, and
(vi) mammary gland discharge fluid. Exfoliative cytology is a means of studying
cells that body has shed during the nomal sequence of growth and replacement of
body tissues. As such the cancer cells are also shed. The test was originally
deveioped to diagnose early cancer of the cervix and now can be effectively used
to study cells shed from the stomach, esophagus, lung, colon, bladder and
discharge froin the breasts. If cancer cells.are found, a biopsy, is always done.
The cells are graded on the following five-point scale.
Class I : nomal
Class I1 : inflammation
Class 111 : mild to moderate dysplasia
Class IV : probably malignant

Class V : malignant
Nursing lltkervention
Explain to the patient that the Pap test is primarily a screening test and that
further examination may be necessary to confirm a diagnosis.
e Explain to the patient to keep the area of discharge clean before the
procedure.
2) Biopsy
A biopsy is a surgical excision of a small piece of tissue for inicroscopic
examination. Usually any woman who has a positive Pap smear for cancer will be
asked to follow it with a ciopsy of the cervix. The frozen section biopsy
technique enables a tissue specimen to the rapidly exa~ninedduring an operation
'when it must be immediately determined whether the tissue is benign or Introduction to
Oncology Nursing
malignant. Needle or aspiration biopsy is used mainly to obtain tissue samples for
identification from the liver, kidney, spleen, lung or breast.
3) Carcino-embryonic Antigen
The carcino-embryonic antigen (CEA) test is done on a sample of blood for the
diagnosis of metastasizing carcinomas of the colon. The foetal gut tissue and the
carcinoma are abundantly supplied with the enzyme (CEA) and it gets released
into the blood stream only when the carcinoma gets metastasized. High levels of
CEA are also found in cigarette smokers. persons with benign neoplasms and with
inflammatory diseases such as ulcerative Colitis. CEA levels, greater than 20 mgl
ml, are highly suggestive of malignancy.
4) Breast Self-examination
Every woman should learn how to examine her breast for possible signs of
abnormalities one a month following menstruation.
Women who have had benign tumours removed or who have had a mastectomy
should be particularly conscientious in the inspection of the breasts. If a lump is
felt, a physician should be consulted immediately. The method of palpation is
demonstrated in Fig. 5.1.
Fig. 5.1: Palpation: How to feel the lump in the breast
5) Mammography
Mammography is a safe, simple non-invasive technique for detecting the presence

of breast tumors. Using a low energy beam, films of the soft breast tissue are
taken without the use of a radio-opaque medium. Mammography is combined
with the physical examination of the breast by a health care provider to find early
breast cancer. This procedure is recommended for women who have the following:
Musculnskeletal, Gastrnintestinal signs and symptoms of breast disease,
familial history of breast cancer,
a previous breast biopsy or breast surgery,

large pendulous breasts that make palpation difficult
when adenocercinoma is suspected.
Mammography is not used as a routine screening test for woinen over 50 years of
age but it is recommended that women should have a baseline mammogram
between 35 to 39 years of age, and mammography done every 1 to 2 years during
40 to 99.
6) Xerography
In xerography or xeromammography, a selenium-coated plate is used and exposed

to X-rays, then developed. It provides improved visualization of the breast and its
structures including the skin. The xerogram has several advantages over the
mammogram. The patient is exposed to less radiation and the procedure is a
simple one.
;r
7) Thermography
Thermography is a technique designed to locate breast

palpable. The purpose is to locate hot and cold areas
The tumour is portrayed photographically as an
skin.
8) Computed Tomography
Computed Tomography (CT) also known as computerized axial tomography.

(CAT scanner) is a computer aided X-ray examination that is proving to be a
major breakthrough in diagnostic techniques. This diagnostic device can be used
to detect tumours and other pathalogic conditions as discussed in early urrits. -
Since X-rays are focused on a few thin layers of the patient's body, patients
receive no more radiation than with a conventional X-ray examimlion. The
procedure is safe, painless, non-invasive and requires no spe~i&c+&~$$garation of
follow-up. .. ."6"
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-1
. :;*
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9) Nuclear Magnetic ~ c s o n a q Imaging
i k
Nuclear Magnetic Resonance Imaging (NMR or MRT) identifies abnormalities

without the use of contrast dyes or radiation. It provides clear images of internal
structures in response to the magnetic field cmated by low energy radiowaves. It
does not differentiate benign from malignant growths but is useful for staging ~ n d
high risk screening. It makes soft tissues within the bony structures vlsible. But
the procedure is costly and lengthy.
10) Ultrasonography
{Jltrasonography or ultrasound, uses high frequency sound waves to detect and

map echoes of varying densities from various organs and tumours. The procedure
is used to detect lesions in the female pelvis, abdominal lymph nodes and other
areas of the body. It is a non-invasive way to demonstrate the growth of neoplasm
without any radiation exposure.
Introduction to
11) Proctoscopic and Sigmoidoscopic Examinations Oncology Nursing
The rectum and large intestines are the most frequent sites for terminal cancer.
Both proctoscopic and sigmoidoscopic examinations enable the physicians to
visudlize rlpproximately the low 10 inches of the gastrointestinal tract so that
tumours, lsolyps or ulcerations may bc studied by obserbation, examination and
biopsy.
iVursing Interventions
See that all fecal matter is removed before the examination by a cleansing
enema. Laxatives and cathartics are given only if prescribed,
Place the patient in knee-chest position perfectly or in a side-lying position

and drape to exposed the anal area.
ate expfanation to patient about the procedure e.g. that the

not painful but may cause some discomfort.
Give re&:. the patient after the procedurc as the examination is often
fatiguing
Provide some light nourishment.

- .
12) Radioisotope Studies
Radioisotopes are elements that emit rays of energy. They are useful in the
diagnosis of cancer and other diseases for several reasons. They can be
administered in extremely small doses e.g. one billionth of a gram of a
radioisotope car1 be used for administratioil as a tracer dose. With such miniinal
doses, the b@y absorbs a minimal amount of radiation and consequently the cells
be used to study the functions specific organs and tissues. For

example, 1''' GMke test is used to evaluate thyroid function when the thyroid
disease is suspected; a tracer dose of radioactive iodine (113') is given orally to the
person. The radioactive iodine circulates to the thyroid gland and these convert
into thyroxine in precisely the same manner as regular (nonradioactive) iodine.
The scintillation counter or scanner can then trace, locate and measure and tagged
atoms to determine presence of disease.
Also radioactive isotopes are used to locate tumours and lesions within the brain,
kidney, liver, lungs, pericardium and bones. For example, 1;" is used to locate
cancerous tissue; that have metastasized from the thyroid gland to other parts of
the body. The area in which the concentration of a radioisotope ia unusually high
is called a hot spot. The tagged atoms tend to concentrate less densely in the
diseased portion of the orgaii and that area is called as a cold spot. There are
three steps for an organ scan which is painless, non-invasive technique. They are
i) Administration of the radioisotope: A tracer dose of radioisotope is given

orally or by injecticn.
ii) Waiting period: Tlie radioisotope needs to be assimilated by the organs

under study. The length of time for this varies.
iii) Scanning procedures: The person is asked to be still and breath normally
while the scanner measures the radioactive atoms concentrated in the organ
under study and record the findings.
Musculoskeletal, Gastrointestinal
13) Barium Enema
Barium enema is done when the colon above the sigmoid is to be visualized.
Barium, a radio-opaque substance, is given as an enema. The radiologist observes
the filing of the colon using a fluoroscope afier which X-ray films are taken.
After that the patient is asked to evacuate the bowel and then the colon is
distended with air followed which again X-ray films are taken. As preparation for
the procedure, give nothing by mouth after midnight. laxatives and suppositories
are given about at bed time gs ordered, and a cleansing enenla and bowel wash is
given in the morning to clean the bowel.
14) Gastrointestinal Series (GI)
The GI series is an X-ray examinations of the upper GI tract using barium
sulphate. It is used to determine the pathology of the stomach and duodenum. The
patient should be asked to eat or drink at least 6 to 8 hours before the
examination. A mixture of barium is given to drink. The fluoroscope is used to
observe the barium as it passes through the esophagus into the stomach. X-ray
films are then taken at intervals over several hours to study the movement of the
barium from the stomach into the intestine.
Check Your Progress 2
1) Name the specimens that can be examined by Pap smear.
2) Define biopsy in three lines.
3) Fill in the blanks,
a) Carcino embryonic antigen (CEA) test is done for diagnosis of

metastasizing carcinoma of the .......................................
b) Mammography is a .................................... technique for the presence

of breast tumours.
c) Improved visualization of the breast and its structures including the

skin are possible through ..................................
d) Il3I uptake test is done to evaluate ....................................function.
4) What is the main advantage of Nuclear Magnetic Resonance imaging
(NMR)?
................................................................................................................................
Introduction to
5.4 PREVENTION AND CONTROL OF CANCER Oncology Nursing
Prevention and control need to be conridered for (I) promoting research (ii) public
education (iii) control of carcinogenic factors and agcnts and (iv) early diagnosis
when curative treatment is possible.
Cancer risk can be reduced by dietary and environmental precautions. Primary and
. secondary preventive measures adapted by International Cancer Society are given
below.
r , You have a major role to play in prevention and control of cancer. Study Table
5.3. You will get a good idea of primary and secondary preventive measures.
Cancer prevention and cancer control programme is given in Table 5.3
I Primary Prevention I
i) Smokin Cigarette smokmg is responsible for 85% of lung
cancer cases among men and 75% among
women - about 83% overall.
ii) Nutrition Risk for colon, breast, and uterine cancers
increases for abese people.
High-fat diet may be a factor in the development
of certain cancers such as breast colon, and
prostate.
High-fiber foods may help reduce risk of colon
cancer.
Foods rich in vitamins A and C may help lower
risk for cancers of larynx, esophagus, and lung.
Salt-cured, smoked, and nitrite-cured foods have
been linked to esophageal and stomach cancer.
The heavy use of alcohol, especially when
accompanied by cigarette smoking or chewing
tobacco, increases risk of cancers of the mouth,
larynx, throat, esophagus, and liver.
iologic evidence shows that sun
ajor factor in the development of
d that the incidence increases for
among heavy drinkers of alcohol.

Increased risk factor for cancers of the mouth,
larynx,throat, and esophagus.
I Highly habit-forming.
For mature women, certain risks associated with
control menopausal
increased risk of
Musculoskeletal, Gastrointcstinal
and Oncology Nursing viii) Occupation Exposure to a number of industrial agents
hazards (nickel, chromite, asbestos and vinyl chloride)
increases risk.
Risk factor greatly increased when combined
with smoking.
Secondary Prevention
i) Colorectal Three tests for the early detection of colon and
rectum cancer in risk persons without symptoms:
a) the digital rectal examination, by a physician
should be performed every year after the
. 1
age of 40; 1
b) stool examination for occult blood is 1
recommended every year after 50%;
I/
c) proctosigmoidoscopy should be carried out
every 3 to 5 years after the age of 50 ,I
following two annual examlnatlons with

negative results. !
ii) Pap test For the average risk person, a Pap test is
recommended annually until two consecutive
satisfactory tests are negative, and then once
every three years.
The Pap test is highly effective in detecting
cancer of the uterine cervlx, but is less effective
in detecting endometrial cancer.
iii) Breast cancer A monthly practice of breast self-examination by
. women 20 years and older as a routine good

health habit.
Physical examination of the breast should be
done every three years from ages 20-40 and
men every year.
A mammogram every year for asymptomatic but
at risk women of age 50 and over, and a
baseline mammogram between ages 35 and 39.
Women 40 to 49 should have mammography
every 1-2 years, depending on physical and
mammographic findings. I
Although primary prevention is the ideal method of cancer control, secondary
prevention involves early diagnosis of malignant diseases and removal of
precancerous lesions.
You must emphasize to the :enera1 public the importance of discovering and
eradicating cancerous lesior early before they begin to metastasize from the
primary site. You must mak people to realize that manifestations of a malignant
disease can mimic those of ,ther less serious diseases processes. The individuals
age, personal health history and family history may be indicative of risk factors
and are vital to the early detection of cancer. As a nurse you have to educate the
.
ueouleL -
bv emphasizing on the need for an annual physical
stressing the importance of early papnicolaou
*
test
-
for
the women the technique fc monthly breast self examination.
examination, by
women and by teaching
I
Finally, we can say that your main responsibility is to increase the awareness of
people about the seven warning signals of cancer as given above CAUTION.
lmplications for Nurses and Health Workers lntroductinn to
Oncology Nursing
Learn the seven warning signals that may mean cancer and teach others
Remember that none of these is a sure sign of cancer

Advise a checkup by doctor if you notice a warning signal
Teach the importance of avoiding delay in getting a checkup for detecting
cancer in the early stages, and treating it promptly.
Learn and teach the public regarding dietary defenses against cancer, which
includes increased intake of
highfibre foods such as raw fruits and leafy vegetables and whole grain
cereals.
dark green and deep yellow fmits and vegetables rich in vitamins A and C,
and
cabbage, broccoli, caulitlower, Brussels sprouts and kohlrabi.
Reduced intake of:
salt-cured, smoked and nitrate cured foods,
fats and oils, especially from animal sources,
alcohol beverages, and

excess calories leading to obesity.
Health teaching ldentlfrcation of Health teaching

regarding risk risk groups regarding hazards of
I Health teaching / Health teaching

I-I
1
1
I
check-up
___?___
I Regular and early / / I
Motivating
"ndividuak
Motivation of sick
to seek and follow
treatment
1
Information
regarding detecting
facilities
Advise check-up
and treatment for
lnformat~on
regarding
/ Surveillance
pre-cancerous diagnostic
lesions facilities
Cheek Your Progress 3
1) List down the preventive measures of cancer in relation to nutrition.

5.5 TREATMENT MODALITIES

To date, the best treatment for cancer cells lies with the standard treatments such
1
as surgery, radiotherapy, chemotherapy and immunotherapy, and bone marrow
transplantation. Early detection and treatment may result in cure whereas delayed
diagnosis and treatment may result in palliative treatment only. We shall have a
discussion of the treatment modalities in the 'following subheadings.
5.5.1 Surgery
Surgery is the major treatment modality for cancer. Surgery may be done for
preventive, diagnostic, curative, reconstructive and palliative purposes.
Preventive Surgery
This may include surgical removal of certain benign or pre-rnalignant lesions such
as surgical removal of a potentially dangerous mole or colorectal polyps or
cervical lesion may be considered preventive surgery.
Diagnostic Surgery
The purpose of diagnostic surgery is to either confirm or rule out a possible
diagnosis of malignancy tissue samples may be obtained for diagnosis and staging
by incisional, excisional or needle biopsies.
I
Curative Surgery i
1
It is the most widely employed method of cancer therapy and is the primary
intervention for cancers of skin, colon, rectum, breast, cervix, prostate and
stomach that are in early stages of development. In many instances the removal of
a malignant tumour before metastases occurs results in permanent cure.
Reconstructive Surgery
It is usually performed after curative surgery or it may be done concurrently with
the radical procedure also. It offers a different perspective of rehabilitation to the
person. It improves the person's quality of life by restoring maximal function and
appearance.
Palliative Surgery
When metastasis becomes widespread, surgery may be only palliative such as an
operation done for relieving an obstruction, or controlling pain. This is performed
when total removal or destruction of cancer cells is impossible. Another example
of palliative surgery is the creation of a colostomy to bypass a cancerous lesion in
the bowel. Although all these types of surgical procedures are widely used,
research is in progress to increase changes chances of cure by surgery. New
surgical techniques and tools have been developed. Cryosurgeiy and laser surgery
destroy cells by thermal mechanism.
Nursing Intervention
he pre-operative and post-operative nursing care of patients having surgical
surgery and will be reviewed in the appropriate section. The psychological aspects Introduction to
Oncology %ursing
need to be reinforced in caring for cancer. as the potential or actual diagnosis of
cancer exists even after surgery.
5.5.2 Radiation
Radiation therapy refers to the use of ionizing radiation to treat vaiiety of cancers.
It may he used to obtain a cure in combination with surgery andlor chemotherapy
or for palliation of symptoms when cure is i~tlpussible.It can be administered
frqm a \ariety of sources such as those outside the body (exicmal radiation
therapy) and those inside the body (internal radiation therapy). We shall disci~ss
each one of these as follows.
External Radiation Therapy
It is usually administered by high energy X-ray mqchines (betatron and linear
accelerator) or machines containing a radioisotope (Cobalt 60). The X-rays are
only produced when the equipment is in operation. Thc major advantage of high-
energy X-ray machines is their skin sparing effect. This means that the maximum
el'fect of irradiation occurs within the tumour deep'in the body and not on the
skin. Parients receiving radiation therapy inay experience variuus side effects. See
Table 5.5 for the early, intermediate and late effects of external radiation therapy.
1 Time of Occurrence
Earlylacute; caused by death or normal
cells 1 Skin reactions
Dry desquamatlon
Nausea
Vomiting
Diarrhoea
Fatigue
Bone marrow suppression
- -
Cystitis
Intermediatelchronic; caused by small- Radiation pneumon~tis
vessel changes resulting in decreased Radiation-induced heart disease
luman thickened wall of vessel Radiation-induced paresthesia
Late Tissue necroses
Fistulas
Nursing Intenlention
Study Table 5.6. This gives a summary of nursing intervention for external
radiation therapy.
/ Be sure you are familiar with the patlent, his chart and problems:
I the type of radiotherapy prescribed
I the site of tumour undergoing radiation i
i
--L
0
purpose of therapy-palliative
number of radiation planned
-
or curative
Check the knowledge and understanding of ~ a t i e n tabout the therapy.

Instruct about the skin nlarkings that the radiotherapist makes and not to erase it
until treatment is finished.
Answer all the questions in a pleasant way; give psychological reassurance like:
Musculuskeletal. Gastrointestinal a radiotherapy is painless, no sensation is felt as such.
a to be still on a special table,
a to remain alone while X-raylteletherapy units are in operation,
a can talk over an intercom to the technician outside observing through a
window or television,
a different ports (area through which rays pass into) are used on different days
s o position may be changed slightly at intervals.
Skin Preparation
a Remove any ointment or dressings
a Thorough cleaning of skin usually an alcohol rub is given
a Get the area outlined--the area to be treated is usually outlined by the
radiologist at the time of first treatment. Instruct the patient not to wash off
the marks until the treatment is completed because they are important guides
to the radiologist and also not to apply any medicated solution or ointment
on the marked area until the series of treatment is completed
a Avoid constricting clothing as skin gets irritated and breaks down easily
a Avoid hot water bottle, ice caps, exposurg to sunlight and wetting for 2
weeks
a Give high protein diet, maintaih fluid and electrolyte balance
a Nursing personnel to be protected by observing radiation protection principles
of time, distance and shielding; wear a film badge to assess the amount of
radiation received
a Observe for local and systemic reaction
a Provide symptomatic and supportive care
Internal radiation therapy involves placement of specially prepared radioisotopes

directly into or near the tumour itself or into the systemic circulation. They are
called sealed sources in which radioactive material is enclosed in a sealed
container or unsealed sources in which radioactive material is administered
directly. such as by injection or orally.
Sealed source (brachytherapy) includes intracavitary therapy in which the
radio-isotope usually !"cessium or "hradium in sealed applicators are placed into
the body cavity for calculated period of 24-72 hours. Applications may be inserted
into the patient's mouth, tongue, neck, vagina, ccrvix or other body cavity (see
Fig. 5.2).
152 Fig. 5.2: Ernst application in place for treatment of cancer of the cervix
Introduction to
Interstitial therapy involves the packing of radio isotopes in needles, beads, seeds, Oncology Nursi~tg
ribbons or catheters (see Fig. 5.3) and then implanting directly into the Malignant
tumours temporarily or permanently depending on the half life of the source being
used (see Fig. 5.4) which shows radium implantation into the tonsils. The
unsealed sources are used in systemic therapy. Radioisotopes are administered
intrave11c)usly or orally. For example Iodine"' is given orally in very low doses to
treat Grave's disease or in high doses to treat thyroid cancer.
Jugular veln
Subclav~anveln
.Superior vena cava
Dacron cuff
.Right atr~urn
Exit site
her-Lok
.Right atrial
catheter cap
Fig. 5.3: Placement of catheter in the chest wall
Cancer of tonsil
Radon seeds
Fig. 5.4: Radium implantation insertion into the tonsil
~lr,,rsingintervention
While giving nurslng care to the patient undergoing radiation you sllould learn
how to avoid excessive exposure to radiat~on.This can be done by using three
main pri~~ciples
of' radiat~onprotect~on.
Distance: Greater the distance from the source of X-ray, lesser will be the
exposure.
Musculoskeletal, (;astrointestinal Time: Less time you spend close to a radiation source. the less you will be
a r ~ dOncology Nursing
exposed,
Shielding: Using Lead or other materials to ahsorh (see Fig. 5.5) radiant
energy helps reduce radiation exposure.
4 1 22 meter 2.44 meter Distance from

raalatton Sotiice
2 feet 4 feet 8 feei
I i
I I q r a c t ~ o nof total
Total :'4 1115 7/64 rad~at~nn expostire
Fig, 5.5: Distance Sl-0111radiatio~lsource: fraction of total radiation exposure
Nursing lr~terventionfor lnternal Radiation Therapy

He familiar with the patient. his conditions and his file as !o:
what radioisotope is to be u ~ d
- - tbpe of source (sealed or unsealed)
mode of action (interstitial, intracav~tary,systemic)
- s ~ t eof implementation if sealed
number of days requiring isol?t'Ion.
G ~ v eproper expla~lat~oli
about the purpose and procedure and reassure patiznt
nnd bigniticant others.
I t ' >enlid ill ~ieedlcs.hi:ad> or- c\lrcs preparc the patient for a silrget->
No special preparation for systemic adniinistr~rtion.
Str~ca!soldt~ondttcr ~mplan~ation,in a bath attached room with another

patlent r e i c i ~rrig the same.
Kecp radintlon piccnu!ion sign at the door for restricting \,iaitors.
e Explain the routine to the patient ailti the I-eason for the precaution (patient is
a sourci: of radicractivity as the irnplantcd or in.jected radioisotope continues
to emai;ate rays of radiant energy).
Provide a clear unit with extra articles (ptllows, backrest, cardiac table) arid
Gcilities like intercom. television, radio; etc.
Wear isolation gown and gloves and a film badge while caring for the Introduction to
Oncology Nursing
patient.
Instruct the visitors to maintain some distance from the source; restrict
pregnant women and children fiom visiting.
Notify the radiation officer if a radioactive source is spilled, dropped o the
floor, lost or accidentally discarded.
Use a long lead forceps in case of dislodged isotope.
Save all dressings and bed linen till the radioactive source is removed.
Encourage the patient for self-care.
Maintain measures of self-protection; limit time spent in the room, keep safe
distance from the patient and use shielding (lead apron, gloves) devises.
5.5.3 Chemotherapy
Chemotherapy evolved in the 1940s with the therapeutic application of nitrogen
mustard. The objective of chemotherapy is to destroy all malignant tumour cells
without destruction of normal cells. Normally cells respond to body's need for
growth, repair or regeneration in an orderly manner and cease production by
entering a resting phase or slowing growth when. the need is met. Cancer cells
reproduce in the same manner as normal cells. But the growth continues in an
uncontrolled manner.
Well what does chemotherapy to do these cells? Chemotherapy directly or
indirectly disrupts reproduction of cells by altering essential biochemical
processes, thereby-a control or eradication of all malignant cells is possible.
The chemotherapeutic agents are generally classified according to their mechanism

of action. A summary of the common chemotherapeutic drugs and their action is
given in Table 5.7.
1 Cyclophosphamide I which bind to DNA I solutions for clarity; mix 1
4. Haemorrhagic cystitis as a
result of chemical irritation
General toxicities:
1, Anorexia, nausea,
vomiting
2. Bone marrow suppression
3. Alopecia
Classification Frequently Used
Medications
~ e c h a s
of Action
- 1- Nursing Implications
and General Toxkities
-
--- ,
Mithramycin (Mithracln) 1. Bone marrow suppression

Daunorubicin) Bleomycin 2. Nausea ind vomiting
Sulfate (Blenoxane) 3. Stomatitis
4. Alopecia
Disrupt mitosis by 5 , Cardiac abnormalities
bind~ngwith 6. Pulmonary abnormalities -
microtabular spindle 7. Fever and chills
Interfere with
(Oncovin) Vinblastine subcellular hormone- General toxicities:
sulfate (Velban) receptor proteins 1. Bone marrow suppression
Etoposide (VP-16) 2. Nausea and vomiting '
i 3. Stomatitis
1 4. Hypotension
:
5 . Neurotoxicity
General toxicities:
Estrogen Megestrol 1. Nausea
acetate 2. Fluid retention
(Megace) Frednisone 3, mood changes -
Dexamethasone 4. weight gain
General toxicit~es:
(ccns) Aminoglutethimide 1. Hot flashes
2. Nausealvomiting
3. Anorexia
4. Requires mineralocorticoid
replacement
General toxicities:
drugs 1. Bone marrow suppression
2. Mild nausedvomitingl
anorexia
3. Infrequent alopecia, skin
changes
L-Asparaginase (ccs) Blocks essential General toxicities:
amino acid 1. Increasing risk of
hypersensitivity
4-
2. Elevated liver functlon
studies
3. Nausealvomitinglmalaise
Procarbazine (ccs) Inhibits RNA, DNA, Monoarnine oxidase
protein synthes~s inhibitor; restrict
tyramine-rich foods
General toxicities:
I.Bone marrow
suppression
2. Malaise
3. Nausealvomiting
Administration of the Drugs

Chemotherapeutic drugs can be administered by variety of routes depending upon
the property of the medication and the purpose of the therapy. It may be
prescribed by oral intramuscular subcutaneous and intravenous routes and can be
administered singly or in combination. Presently, the combination chenlolherapy is
given as it decreases the potential for developlnent of resistant cells and lowers
the remission rate as compared to the drugs used singly.
These drugs must be given with great caution and your major responsibility is to
watch any side effect during therapy and report to the appropriate authority. These
Introduction to
Oncology Nursing
Busulfan (Myleran)
Cholorambucil (Leukeran)
Ctckiogisoganude (Cytoxan)
Dactinomycin (actinomycin D)
side effects can be the major limiting factor in their use. Study the Table 5.9. You
will understand the side effects of ,the chemotherapeutic drugs on various organs
and systems of body.
Remember that all Chemotherapeutic Agents are Potentially

Dangerous-Monitor the side Effects Vigilantly
The nonspecific complications of cytotoxic drugs include nausea, vomiting and

alopecia. Many of these drugs have effects on the bone marrow resulting in
infections. The nursing guidelines and precautions for safe administration of
cytotoxic agents are given in Table 5.10.
5.5.4 Biotherapy
Biotherapy is the use of agents called biological response modiJiers ( B R M ) that
modify the relationship between the host and tumor by altering the biological
response. Three categories of BRM's exist:
Agents that have direct antitumor effects
Agents that restore, augment or modulate host immune system
mechanism.
Agents that have other biological effects such as interfering with the cancer
cells ability to metastize or differentiated.
Bone marrow Leucopenia 1 Most drugs, with the exception of
Thrombocytopenia steroids Bleomycin, L-asparaginase
I
Gastric intestinal Stomatitis Adriamycin, belomycin, methotrexate,
tract 5-fiuorouracil, actinomycin.
1 11 Diarrhoea
Paralytic ileus
I1 Vincristine
Methotrexate. 5-fluorouracil
1
I I
Skin
Nervous system
Hyper pigmentation,
Alopecia / Bleomycin, busulfan adriamycin,
Cyclophosphamide, actinomycin D
Paresthesia peripheral- Vinceristine, Vanblastine Cis
neuropathy Deafness Platinum L asparaginase
Heart Cardiac fa~lure,with Adriamycin, dannomycin
Lungs Fibrosis (late) Belomycin, busulfan,

Methotrexate, cycio phospharnide
Pancreas 1 Panereatitis
I
( L-Asparaginase
I
1
I
Uterus Uterine bleeding Estrogens
Bladder Cystitis Cyclophosphamide
Liver Abnormal liver L-Asparaginase, mithramycin
function
Kidney. Abnormal kidney Methotrexaje, .Cis platinum,
function mithramycin.
Anticipate possibility of extravasation andlw hyperse

carry out immediate measures.
0 Seek assistance of a co-worker after two unsuccessful vein punctures.
a Strict aseptic technique should be observed for each stage of the
procedure.
a Prepare the mediqation with extreme concentration in a quiet, unhur
environment.
Never use chemotherapeutic agents to t
a Each vein must be tested with normal s
Stop infusion anytime when vein patency is in question.
Protect yourself by the use of aprons, masks and goggles.
Give all chemotherapeutic agents slowly over a period of 2-5
I Monitor the blood results closely and notify the doctor if any leucopeni
present.
Monitor the patient during the entire time of administration and a
all the side-effects.
Anaphylactic shock may occur with any drug; stop infusion
Take extreme care that these patients do not develop any sort of infection.
a Always be compassionate to such patients. Encourage them to continue
the full course of treatment.
The common agents used as BRM's are: Introduction to
Oncology Nursing
1) ln'terferon a natural occurring complex protein of which there are three
types:
a). - alpha. : interferon produced by lymphocytes
b) beta : interferon produced by fibroblasts and macrophages
c) gamma : interferon produced by T-lymphocytes

All of them inhibit DNA and protein synthesis in tumor cells and stimulate
the expression of tumor associated antigens in tumor cell surfaces, thus
increasing the potential of immune response.
2) Interleukin-2 (IL2) is a cytokin produced by T-lymphocytes and is capable
of stimulating division of .T-lymphocytes.
3) Monoclonial Antibodies are immunoglobulins produced by B- lymphocytes
that are capable of binding to specific target cells including tumor cells.
4) Tumor Nacrotidng Factor (TNF) is a cytokine released by macrophages
and it ultimately hinds to specific receptors located on cell membrane. TNF
is toxic to animals and human tumor cells by exerting a nacrotizing effect.
5) Colony Stimulating Factor (CSF) are group of glycoproteins, produced by
various cells, which stimulates production, maturation, and function of cells
of the haematological system. They hasten recovery from bone marrow
depression after standard and high dose chemotherapy and BMT (bone
marrow transplantation).
5.5.5 Bone Marrow Transplantation

BMT was attempted in the early 1950's with very disappointing results. All
patient's treated were in late stages of their disease and relapsed following
transplant. By the late 1970's with improvements in supportive care such as
modern antibiotics and parenteral nutrition and advances in basic sciences such as
tissue typing, BMT is no longer considered a last resort for the treatment of
certain diseases.
Indications
a) ' cancers responsive to high doses of chemotherapy or radiation therapy
b) acute myloid leukemia, acute lymphocytic leukemia. Chronic myeloid
leukemia, multiple myeloma
c) hodgkin's lymphoma
d) neuroblastoma
e) genetic diseases- thalassemia, sickle cell anaemia, immunodeficiency disease
I
f) aplastic anaemia
1) Syngeneic-where the donor and recipient are genetically identical
2) Allogenic-where the donor and recipient are of the same species e.g. human
to human.
3) Autologous-where patients own bone marrow is used following cytotoxic

therapy.
As with any organ transplant the problem of organ or tissue rejection- isamajor
consideration. The ideal donor for BMT is an identical twin because the donor
Musculoskeletalq Gastrointestinal and the recipient are genetically identical for all transplantation antigens. Siblings
of prospective patient have 25% chance of being perfect matches.
Preparation of donor--A donor is found by obtaining blood samples, usually from

sibl~::gs, for compatibility of tissue typing. In absence of siblings, it is possible to
have an unrelated donor.
Procedure
a In most cases prior to transplant, chemotherapy and total body irradiation are
given to induce immubosuppression and to eradicate residual leukaemia cells.
a 500 ml. to 800 ml. of blood and marrow are aspirated from the donor under
general anaesthesia. The marrow is mixed with heparin and strained, then
immediately administered intravenously to the recipient.
a Observe general principles of intra-operative nursing care such as monitoring
vital signs and maintaining venous access.
Nursing Interventions
a Isolate the patient for at least 6 weeks to minimize infection.
a Provide emotional support to patient and family.
a Guard against any kind of infection.
a Explain to the patient and family about the possible co~nplicationslike
septicaemia, bacterial and fungal infection, pneumonitis and marrow failure.
a Get a written consent prior to procedure
a Educate about the long term effects; cataract, sterility, arthritis, graft venous
host disease.
1) What is Biotherapy? List its categories.
.................................................................................................................................
2) List the types of BMT
3) List the metabolic oncologic emergencies

Introduction to
5.6 ONCOLOGY EMERGENCIES AND NURSING Oncology Nursinp
INTERVENTIONS
If oncology emergencies are not identified early and treated, it can result in severe
morbidity and death.
Oncologic emergencies can be grouped as follows:
Metabolic infection and pain, hypercalcemia, tumor lysis syndrome, syndrome of
inappropriate anti diuretic hormone (SIADH), and disseminated intravascular
coagulation (DIC).
Structural spinal cord compression, superior vena cava syndrome, cardiac
tamponade.
Metabolic
Infection and Pain
Infection can quickly progress into a life threatening emergency in the client with
neutropenia. Pain is present in almost 60 to 90 % of people with advanced cancer
have pain. Its management has already been discussed under palliative care.
Hypercalcemia
It is due to bone resorption (demineralization) and is defined as a serum calcium
level greater than 1I mg./dl. If the level rises suddenly, renal failure, coma,
cardiac arrest and death can result. If the calcium level rises slowly, the client
may be relatively asymptomatic.
Nursing management includes adequate hydration, and mobility in the clients at
risk. Medical management is aimed at controlling the growth of tumor causing the
hypercalcemia and administration of drugs to lower the calcium levels such as
calcitonon and oral glucocorticoids.
Tumor Lysis Syndrome
This is a potentially fatal metabolic emergency that can develop as a tumor
responds to treatment. During this process the destruction of malignant cells
release intracellular potassium, phosphorus, and nucleic acid into the circulation.
Electrolyte imbalances and acute renal failure usually begins 1 to 2 days after the
treatment starts and end within a week following the completion of therapy.
Medical management begins with adequate hydration before beginning of
treatment and contd. after the treatment. The goal is to remove potassium from the
extracellular fluid with medications, retention enemas, or 50% dextrose IIV which
acts to increase plasma insulin and thereby forces potassium back into the
intracellular fluid.
The most important nursing interventions include:
Observe the clinical manifestations and report weakness, nausea, diarrhea,
flaccid paralysis, ECG changes, muscle cramps, oliguria, hypotension, odema,
I and altered mental status.
Maintain fluid and electrolyte balance and hydration.
1 Monitoring of weight daily and record of intake and output.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
It results from the abnormal production of antidiuretic hormone. It leads to
decrease in sodium levels and water retention. It is not a preventable complication
I
but it is a medical emergency when the hyponatremia is severe (<I20 meq1L). In
I
I
IV infusion of hypertonic saline (3-5%) is given in severe cases to prevent
~ u ~ c u l o s k e l eGastrointestinal
~l~ pulmonary edema. Intake output is monitored and drugs given are: Declomycin,
lithium, and urea.
Disseminated Intravascular Coagulation (DIC)
It involves the development of extensive, abnormal clots throughout small blood
vessels. The widespread clotting consumes all circulating clotting factors and
platelets, leading to excessivi bleeding from several sites. The clots can block the
blood vessels decreasing blood flow to major organs.
In clients with cancer DIC is caused by gram negative infections, release of
clotting factors from cancer cells, or blood transfusions. Management involves
treating the cancer
Structural
Spinal Cord Compression .
It is caused by direct pressure on or decreased blood supply to spinal cord. Back

pain is the only early presenting symptom, occurring in 95% patients. Other
manifestations include motor weakness, and decreased sensation.
In a client with known cancer, new onset back pain should be a 'red flag'
signaling immediate evaluation. Treatment usually is radiotherapy of the involved
area and a Laminectomy for spinal cord decompression is an alternative. In
hospice care setting where life expectancy is limited to days or weeks,
administration of steroids to lessen the inflammation and swelling around the
spinal cord can be effective.
Superior Vena Cava Syndrome
It is a disorder resulting from internal or external obstruction of the superior vena
cava. It is an emergency because it can interfere with respiration resulting in
dyspnea, facial swelling with jugular venous distention.
It is generally secondary to cancer of lungs. The goal of management are to
provide rapid palliation of the distressing manifestations and to treat the
underlying cancer. External beam radiotherapy is the standard of care of
palliation.
Cardiac Tamponade
This prevents heart from filling and contracting normally. The onset may be
gradual. The most common manifestations are tachycardia, severe dysnea, cough,
pain edema and hypotension. Medical management includes pericardiocentesis, as
the fluid may accumulate again, it is preferred to do pericadiotomy. Nursing
management includes careful assessing clinical manifestations and teaching family
members and care givers to watch for its manifestations.
5.7 REHABILITATION OF CANCER PATIENTS

Cancer rehabilitation is a physician- supervised program for people who have
undergone treatment for cancer. People who have survived cancer may have
physical, emotional, and social issues that affect their quality of life, no matter
what kind of cancer they have been treated for. Cancer rehabilitation programs can
often improve function, reduce pain, and improve the well-being of cancer
survivors.
The Cancer Rehabilitation Team
Oncologist
Psychiatrist
Retlabilit~tionnursc introduction to
Oncology N u r s i ~ ~ g
nietltian
I'hl \lci:in T% 11h special~ty
P1:ysical therapist
Occupational therapist
Social worker
Psychoiogist
T(ecreationa1 therapist
C'asc nianager
Ch~iplarn
Vocational counselor
The Cancer Rehabilitation Programme

The goal of cancer rehabilltation i \ t o help patizr~tsreturn to the h~ghestlevel of'
function and ~ndependencepos\ible. while rmproving the overall quality of life -
physically, emotionally, and socially. These goals are often met by:
Managirig pain
Improving bowel and bladder f~u~ction
Improving ni:tritional status
11ny:soving pliysicul conditioning, cndura~lce,and exercise performance

0 Ilnprovin social, cognitive, en~otionnl,and vocational status
e Reducing hospitalizatious
In order i c ) I~elpreach thesc goals, cancer- rehabilitation programs may include the
following:
Usitig rncdicatinns a t d pain marlagernent techniques to reduce pain
Exercise programs to help 'build slrct~gthand endurance
0 Patiz!:t and family education and counseling
Activities to improve mobility (movement) and decrease sleep problems
P Assistance with activities of'daily living (ADI,) such as ealing. dressing,
bathing, toileting, handwriting, cooking, and basic housekeeping
e Smoking cessation
Stress, anxiety, and depression management
Nutritional counseling
Management of chronic illness or complicatjons due to cancer treatments
Vocational counseling
Seven major rehabilltation nursing strategies must be considered in helping the
cancer patients achleve maximum health. Nursing strategres must be considered on
positive person lo person interactions related to discase situation in order to
promote a greater degree of patient and f'amily health. Seven areas to discussed
are:
Education
Seif case
Musculoskeletal, Gastrnintestinal Communication
Sexuality
Mobility
Biophysical functioning
Vocational rehabilitation
So rehabilitation nursing is based on a philosophy of hope and survival for the
patient and family confronted with cancer. The nurse plays a major role of co-
ordinating in helping the patient to achieve the goal of living.
5.8 PALLIATIVE CARE

5.8.1 Concept of Palliative Care
Palliative care is a concept of care, which provides compassion, concern, support
and skilled professional care for the dying. It is derived fi-om the Latin word
"pallium" meaning cloak or cover. In palliative care symptoms are cloaked with
treatments whose primary aim is to promote patient's comfort.
Definition
1) "Palliative care is the total care of patients whose disease is not responsive to
curative treatment. Control of pain, of other symptoms, and of psychological,
social and spiritual problems is paramount. The goal of palliative care is the
achievement of the best quality of life for patient's and their families"
(World Health Organization, 1990)
2) "Palliative care is the active total care of patients and their families by a
multi professional team at a time when the patient's disease is no longer
responsive to curative treatment and life expectancy is relatively short ".
(Robert T-Wycross)
3) Palliative care is the "combination of active and compassionate therapies

intended to comfort and support individuals and families who are Jiving with
life threatening illness". (Ferris and Cutnmings, 1995. The Canadian
Palliative Care Association).
Coals of Palliative Care Approach
The goal of palliative care approach is to attain the highest possible quality of
life, which refers to subjective satisfaction expressed by an individual, which is
influenced by all dimensions of personhood-physical, psychological, social and
spiritual.
5.8.2 Elements of Palliative Care

a) Affirms life and regard dying as a normal process.
b) Neither hastens nor postpones death.
c) Provides relief from pain and other distressing symptoms

d) lntegrates the psychological and spiritual aspects of patients care.
e) Offers a support system to help patients live as actively pq possible.
f) Offers a support system to help the family cope during the patient's illness
and in their own bereavement.
Radiotherapy, chemotherapy, and surgery have a place in palliative care, Introduction t c ~
g) Oncology Nursing
provided that the symptomatic benefits of treatment outweigh the
disadvantages.
h) Provides a multidisciplinary approach to symptom relief and psychological

support at any point along the cancer illness trajectory.
Teamwork and Palliative Care
Palliative care is best administered by a group of people working as a team,
which is collectively concerned with the total well being of the patient and family.
The team includes:
a Nurses
a Psychologist
a Social worker
a Physiotherapist and occupational therapist
a Volunteers
a Family members
a Religious workers
Palliative Care Service Providers
Palliative care services are provided by:
Home Care Services
a Hospice Units
a Hospital based programme
a Combination of services
Home Care Services: Palliative care services offers services of specialist home
care nurses, consulting doctors at home hospital and social workers. It has
outpatient clinics, day care centers, and hospitals for in-patient care. It also offers
bereavement support for trained volunteers.
Hospice Units: the concept of hospice care can be traced back to medieval times,
although the modern hospice movement is attributed to the work of Dame Cicely
Saunders. She developed the concept of "total pain" and acknowledged the
importance of emotional psychologieal and physical components of pain. In 1967
Dame Cicely Saunders opened St. Christopher's hospice, in Sydenham, a
specialized unit devoted to the care and support of dying patients.
Hospice is not a Place: It is a special kind of care-usually occurring in the
home-for those with the terminal illness and their families. While accepting
death, hospice does not focus solely on it. Rather, it strives to enable patients to
live as fully and conlfortably as possible and to retain control of life's important
decisions. Hospice programmes rely on thousands of trained volunteers who are
dedicated to provide comfort and care to patients and families. However, hospice
is run by professionals-physicians, nurses, home care specialists, counselors,
spiritual caregivers, social workers- who are highly qualified to meet the special
needs>of those with end stage illness and their loved ones. Hospice can offer any
treatment that is necessary to inlprove the quality of life, relieve suffering, or
allow death to occur with comfort and dignity. The overriding principle of hospice
is that any treatment can be considered, not for its life prolonging or curative
: t P 1 intetlt. hill ratller for 11s pajllatl~e11;:cylt - ~ t qa h ~ l ~ t y 2nlla:lce cc.~ntorc oi
and Oncology burring
o t h ~ r t + ~!nlprcve
\r ihe cjualitq of' Ilk.
Qualiej of Life Assessment

Palliative i.:are aims to rl;ainlkiin or irnl~l-ovethe quality 01' life (>I'patienr.:
with ir,curabie illness, 3nd its I~-!~pact may be e\ialuated by rneilsuri~iyq~ia!itv
of life.
a Measures slio~rldassess t-educ.titu: ir: sitffei-in3 ("ili-being") and ~har12t.air;
4
poAtive leelings i-'\vcli-heil?gn),
e The ~ o ! n p ) n t ' n tc~: i c!uai!ty o f liik 111;:1 ~11-cti~iial!) ~ ~ I C Z C L I I i:1~111~!t'
-C~ plt;d,sicitl
symptoms, pl~psicnlpe:-forlnalcc (lirncrlonal statcis). psqci~c?logicalstate :jnd
social interaction.
5.8.3 Comfort in BPalliaiiveCare

. .
Coinfort is defined i?rc?artjv :1s the m1!.:1n?1;.11ig of p~4'il?i)ii,gicdistre';~, ~ l i i l
re;)r<se:lis ihe ,najor i;i ;+ii i;nilccl- palii:nts. partlcu:;:rly ihr k l i ~ ~ ?c ; j~! ~ ~ \:
! tjij;~
-.
ativa;tce$ cancer. Filc:lssi~!g cii proulifin~con~liirttu the ciii-r;t, ii i:a:? :;!ter
lo nurses, i:ompiti?lent the nle~liculgoalsl al-rtl prr;vidc
s;itlsK?i!ig opl~~rti~ilitics
~?eedcclrcso:irccs t:, !he cliei;~and 1!1e f:dlniiy.
co!r:j;ol,ei:t o f sc?n?f'r!r:res:y ti;aii:ly v:jf!;

TI?<p>>ch!?l~gi.~. :lidir,gt Lfic clicni
. .., .. % .
I;.,1 1
t ~ ~<~!l?t!:?Ll~
:,.1<1!~i? ? \!iLii~2d &;$~V~I.LCS df?<I f i : ~ ; ~ ~ ~ ~ ) i-!l,j,
~ ~ ~ ~()l:iXp!
~ l i p : ; .!?:q:iirc~ !l!;ll.
~ i ~~ ~zu ~hcs r; I: \ ,iiiabt~10 iile ciient ant1 i:~:nily ds Ihc) i i ? l ~ t i ; ? i l i ' to live tilcii- ji;ies
hv, ~cl;l!:,:ing
. t o Ir.eel ar; a/lel.i:d pllJs,il,ai a.;.lpi:r:ry ,:;luscJ hi, C5z~!g:": I: f!-:t i:lic:!;i-S
i!::ica>,e :.!,ui.. 'liie~t.i:!1,1172~3 :l~rl) nc related to c:lncer itseit: i o the t!iel.apc.~ric.
ir~l~ncrllions rha: \+ill evc:n~~jaliylend to cdler;!'s de2th. C!lentvs ~;sycho!r!~gii.;ts!c::
arc :iL:p::ndent !(,a !;il-er: c!.egrce 011 iic.w -n.jll ;f:c.y a(!;>i?i i~ :bcsc pllq;.;ic;.rii.~;il?r:-.-:
:hiit :ic:i:ompa:::, ca:~cei-.One (:f rhc nlajc?r r:xprrss~~!l;ae.i, '!i' :ll! callcer par!isnts,
P H ~ I . I C ~ I ihc'ic
~ : . I Y in tiic: ;~ci\:anc:e:l stage. is chat they I~~:i.ometot., bl:r&nsol?lc
th:it I:?.III~I?, i-.e;itk acre prov~ders,and tiiencis ~ v ~ahandoil ll :henl. The nilrse can
~ i ! i t ~ i r ~:hesc
i : l ~ lknrs a grea; iic:ij by maintaining s~.!pporland cor~t;icL.
1) Spiriiual Comfort
Spirit~ii~i C'onil'ort can be bery ~!npor-tarntLO Si>r:le client's, and U~eirwishes and
beliefs rr!eeti lo he respecred hy all licalth care providers. During !$is stage of
carrcttj- \l.,!ien physical limitatiol~may increase, lmny slier!t's an$ their families
firid great solace froin religion, so iht' nurrse shauld rc.::llon:i supportiiely to
request to see clergy or to discuss rheir feelings.
3i Ph) siologic Comfort
!'he p h y ~ ~ o l o gclimens~ons
c to the concept uf comfoit in client with advancetl
Lancer inciuae nutnerous activit~essuch as hyg~ene:act~ttties, rest atd s!eep;
caf't'ty; nutnt:on; eI~lll~nat!on;oxvgenatlon: sensory needs.
5.8.4 Barriers to Delivering Palliative Care

e Kewurce Allocation: Thrre is a need to dllocate ci3ncer care resources across
tile period of the illness.
Culture: Specific ntt~tudesand beliefs view of person and hea!th care
qtmcture
IOh e Policy Issues: Avaiiability of o p i ~ i d$rugs in countrq and their regtilat~on.
In troduc tin18 to
5.8.5 Symptom Control and hiax 3"lanagement Oncology ?ur%ing
,4 groa 1112mal~gnnncyor the local or sysre:l:ic effects of cdncer t r ~ a i n l e l ~sat1 t

al'fecr x. rrtually 1' 11 body systenls, A v,!r:et\ ~r s>r:lptorns can result depend~ngon
tlic Lo$-a:~~)n 11f the tumor and thc spec~:ic roii;ci!~es elf treatment, hurscs canng for
p;,tirl:!\ 1s r r l l cancer need to a n ,!re of ihc i~iort:cornmon symptoms assos~atcd

~ j t l ltlie d~ileaseo! ~ t sirealment. because 3.hrlse tllat nrr ~ a r t ~ c u l a r itf~stressful
y can
icad to :!l(irhldity, ail'ec! cc>n~pllan,~e l.4 l r i t Illit.lT t>ntronc 1;)cus on the prek enllon,
earl? iL.?rctlotl,:nd ~nallngement(,I'i h e a ~~.,)lli;?i;::lr!on~.!t 1, 211 are'i ot patient
~.i,rc t h a ~proc~dcsopportunlt~csto hc ~!e'rtivc i r i ;,lake J \ignificant d~i'lerrnc-=
11; ;)arm~ii.~s yuclrtb o f lil-2.
C'ommo~eS!mpi-onrs Experienced tn !he C'ancer Patients
It (;en be ca~ist:d by prim:try or ~ x e t i ~ s t ~(ljscaae

~ t i c imolt-ing the bull:: n!arro\u al-
by nlyelrisuj~press!ve the~-~lpy. 7't;c normal 11rucluc1;~nof' I~aemopoieticcells is
11 LC; , ~ s ~ r l t i nin
g graiiulocytoi>itcnia, rhronlbocytc~peciaanti anaeri-~ia.
-3 8. ,.I <
Wurst:.; sh(;uld euucate patients ahour the slgr!.; i111{l >yii?l:toi~ls( i t

eran~jlor.;itorr?e~?ia. !-i!ro:nbocyio~~i;~ii:i~
ik:lc! aracic!!?ia.Patie!~rs~ihoilldnj<;c? be
in!i!nned of !lie pc>tential hi.klecding and int:reasccl su~r.:.pt!i::lity.to intb-ction
assc>cia!~~il.\i,itii iow plateiet an;! whit,: bliroti cell counrs. i!~tectiilnprevention
shcwici hi. s~resscti.
hursing lnt-e~.vem~tions: i n c i ~ i r !f:dit~ntii:rr

~ pxien?; ab:!~rt anticmetics sr.-i-iclluling
1
1 . . .
5t-~.,~ , r :htx .~
s t p;rtients r.a:zci\;e a1:Licinit:t:i.s :7r:!i?r2 trearnlcill anti on a scl~ed~:ic:d

ar.ot:~?iiii?c clock basis f(?r 31-77 hi-s. li-ll..!:vltle trc.arl~~t:!ii, c>li:;l: i ~ i.high iiosagt>.
and In ir~nsbiiiatloi~c. liy adm!??i>ii.ringact1ri::crics ;~roul?i!!he: cloi-k instcad of as
needed. better p:.evel~ric)r?and contn?i of elr;esir can be aachicvcd. %.'u:-ses need
zlso obhtsr\:c tile side-elTecis nf the drzigb and evaiua!ing the patients response to
the antii::!:etic: rcgia~eu.
O n c t ~ l o ~patie~~ts
y lrequently exhibit alterations i!: howc! fur-1ctio11such as
diarrhea. c:::tstipation, aild bowel obs1ructio[1. C'n~nmonc a u m of diarrhoea
include: cliemoti-~crapy,radiation therapy, rii:~ibioticr, graft vcrsus host disease,
bow-e! resection, tbotl intcileranc.~.. iicperr!~n;c~lardietary supplements, t~ibc
i2erlil:gs. etc, rl'l-c;iiment del>ends I ; ~ O I I t h ~ C:ZUS~,
' blit niay ir~cludeantidjarrlleal
.
and nar::citlc agents, avoidar!ce c>i' hicli dic!ary t7hir. and ni!~er bowc!, siinlulants.
a d the restriction of-' oral fluids ro resi tlie bowel.
Cc?nstipation can r c s ~ ~fro111

lt ln~!?silni;:nt ot' perlstaitic: acti~,ity,chernolhrrapy.
narcotic analgesics. immobility, changes in eating hahits, dehydration etc.
Q3onstipation can be managed hy j?rci:enIi:.;e techniques, including the eliminatic~n
of causative factors, or by judicious use of stool softenzrs. Patients who are at
risk Iijr constipation should be started on a prophylactic bozvel regimen that
includes a high fiber diet, ~ncrt:aszd Iluid intake, bulk f(311ning agents, and stool
softeners.
i Rowel Obstruction: Most fiequenily occurs in patients with advanced a1)dominal

rnaligna~?cies,ovzrian cancer, or adhesions caused by prior surgery or radiation
therapy to the abdomen. Initially. patients may be treatzd conservatively with
t
~lusruloskeletal, Gastrointestinal nasogastric suction and restriction of all intake; some may require surgical
intervention to relieve obstruction.
4) Mucositis
Cytotoxic chemotherapy and radiation can damage the epithelial cells lining the
gastrointestinal tract. Although toxicity can affect all mucosal surfaces from the
mouth to the anus, majority of symptomatic complains are related to inflammation
of the oral mucosa, or mucositis. Symptoms usually begin 5 days to 2 weeks after
therapy starts, so preventive oral care should start as soon as therapy stark. The
interventions include mouth rinses or coating agents. Use of antifungals and
antivirals to prevent infection.
5) Alopecia
Treatment induced alopecia (hair loss) can be a devastating physical and

emotional event. for the cancer patient. Hair loss is pr~marilyseen in patients
receiving chemotherapeutic agents. Alopecia results from the cytotoxic treatment's
disruption of the mitotic activity of their hair follicle, which weakens the shaft
and causes hair to break. Hair loss begins usually 2 to 3 weeks after the initial
treatment, and regrowth occurs within 8 weeks of cessation of therapy.
When alopecia is anticipated, nurses shoul'd prepare patients for the possibility of
hair loss and discuss with them the option of purchasing a wig before therapy.
Patients vary in their responses to hair loss and altered body image. Nurses can
assist patients in understanding their feelings and in using a variety of head
coverings:
6) Pruritis
Although pruritis does not occur as frequently as the other symptoms but it can
cause discomfort and impair the integrity of the skin, reducing its effectiveness as
a protective barrier. This symptom can be a clinical manifestation of a local
hypersensitivity reaction to chemotherapy, radiation therapy, antibiotics or opiates.
7) Pain
Many people with cancer experience pain. Thirty to f o Q percent of patients in
active cancer therapy and 70 to 90% of' patients with advanced cancer report pain.
Cancer pain inay be caused by :
a Tumors pressing on the organs, nerves or bone.
a Treatment such as surgery, cheinotherapy or radiation.
a Other conditions related to cancer, such as stiffness froni inactivity, nluscle
spasms, constipation and bed sores.
a C'onditions unrelated to the center, such as arthritis or migraine
Principles of Pain Management (by WHO)
I) By Mouth: Oral route is the choice of ad~uinistrationof analgesics and other

medications as possible.
2) By the Clock: Analgesic medication for inoderate to severe pain should be

given on a fixed dose schedule al.ound the clock, not 'as needed' basis.
3) By the Ladder: l'he WHO has developed a three step analgesic ladder to
guide the sequential use of drugs in treating cancer pain.
4) For the Individual: lndividual requirenients for analgesics vary. The dosage
must be titrated against the particular patients pain.
Introduction to
Oncology Nursing
Fig. 5.6: Principles of pain management by
Usc c?f'Adjzlvunt: It is used to:

Enhance analgesic effects (corticosteroids. anticonvulsants)
Control adverse effects of opioids (antiemetics, laxatives)
Manage symptoms that are contributing to the patient's pain.
Take nothing for granted

Be precise in history taking
Explore the patient's 'total pain .
Determine what the patient knows about the situation, hidher beliefs and
fears about pain.
lnstructions to patient both orally and in writing about administration of
medication.
Treatment of Pain
Treatments that can successfully control pain include:
1) Pltarmacokogic~alTlzerupies (Medications)
Non-opioids pain relievers
Opioids
Ad-juvant medications (drugs whose primary purpose is not for pain but
rather for othcr conditions).
Topical treatments (drugs are applied directly to the skin, as a patch. gel
or creain).
2) Non-pharmumlngicaI Treatments
Non-invasive --they include:
Therapeutic exercises. heat therapy, cold therapy.
Non-invnsive stirnulatory approaches-transcutaneous electrical nerve
I stimcllation.
!$lurs~~iosE.clet&<,asirc;i:!iz-.?inal a Psvchoiogrcal :;pp~t:'zcJ?c?s C:ogniii\e hel~:-i.viou~-al tcchr!icjues (clecp
and Or,c<:logg Suriing
hrtatiling, il.;tagcl);. :~1t~i.;?8fi;:11.
i.inkeiib:lc;t therapy, z!not:!tn~I
reasoning). jxiyzhother:.lay nnd .:~ci;ri slipport.
e !nessagc.
Cs~mpIimciitary/a!te!t.~ativt.npproaci1es.--.~~c:upi~neture.
I n \ , ~ i ~;;on-pharnnacologica1
v tpeatraents iiiclude:
o Anacsthsioiogic approaches: i l e n e l.?!c;::ks. epidural injections.
I
intraspirlal dnlg ati;nir?is;i.atic~~z.
\
8 lnvasive stirnuladory appraaclres: ins~isiveNerve stin~ulatio,~,
spinal
cord stimulation, deep brain stin~iulaticn
C fit.& ]bur Progress 5
1) \V-Flat is p;illlarlve c;lrr :IS g:\ en b! 'I, 10"
.............................................................................................................................
2) 1.ist the prii~cinlesof pain nianagernol-!t as g i ~ e nby WHO.
i n hi< mit. yoel 11:!vc read ahnut the b:isic co:lce;lis of cancer and Its
i.;,itiar~io[ogicalaspec.:~. C'ancer cis Y O i ; kncw: is onc of the niajijr cauw of death.
? lit e~~!pt!asis
L", i is also piciced in the Seiii;!!; :!n:! t:-iai!'gna~~t
neopiasms. etiology of
CRI,,ICi. ,-..
L L l l ~ jstagiilg S ~ S ~ C I T Cora111o11
I. ~li.clig~~i>stic along with 111lrs1ng
~neilsi~res
intcrt cntions ere ~:r,piailied nli detai 1.
Cionci:!,lof p;i!!iativt- <:are its: elerneuts. scc~;li. itlid symptom managcmei1t was nlsv
dcult wii!~ \,T;~r-ious treatment rnc~daliticscsed to treat cancer are also discusseti.
includi!~? i;ol;t: ;rr:\mi)w transplant:tti:!~. 0ncologi~:al erncrgencics are a l ~ ndisc~.~ssed
in detdrl and tl'rei:' n?anapement. In :he end reh;tbiii+aiion of patierits suffering ~ , i d l
cancc: I S eexpl:iir,ecl giving nece:;sary details.
5.10 K& WORDS

Benign i%growth that cbc)c\ n?ot infiltrate or cause
metastasis and 1s unlikely to recur ~f removed
Carcinogenic agents : ilgcnts which produce or prcdrspose to cancer
Genetic : (. oncerrlod writh or!gin or I-eproductron

Introduction
Isotope One of several forms of an element with the same Oncology N I I ~ \ ~
atomic number but different atomic weights
Malignant : A term used for a type of growth which invades

and destroys tissue, which can also spread to
neighbouring tissues and to more distant sites via
the blood and the lymphatic system
Metastasis The transfer of a disease from one part of the

body to another through the blood vessels via the
lymph channels or across the body cavities
Neoplasm : A morbid new growth

Oncology : The scientific study of tumours
Palliative : Treatment which relieves but does not cure disease

Radioactive isotope : An unstable isotope which decays and emits
isotope alpha, beta and gamma rays
Sarcoma A malignant tumour which develops from

connective tissue cells and their stroma
5.11 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1 '
1) a) Cancer cells divide and multiply in a disorderly, uncontrolled manner.
b) They differ in size, shape and appearance. They are usually larger than
normal cells and have a bigger nucleus.
c) They develop antigen that are completely different from normal cells
and exist as parasite occupying space and drawing nutrition from the
host body.
2) Benign Tumor Malignant Tumor
grows steadily and slowly growth rate varies
remains localised metastasizes
usually encapsulated rarely encapsulated
smooth, well-defined on palpation irregular and more immobile on
palpation
resembles parent tissue less resemblance to parent
tissue
crowds normal tissue invades normal tissues
recurrence rare recurrence common
rarely fatal fatal, if not treated
3) a) fibroma.
b) lipoma.
c\ leinmvnma
M~sculoskeletal,Gastmintestind d) sarcoma.
and Oncology Numhg
e) leukaemia.
f) lymphomas.
4) a) viruses
b) chemical
c) physical agents
d) hormones
e) genetic predisposition
5) a) change in bowel or bladder habits
b) a sore that does not heel
c) unusual bleeding or discharge

I d) thickening or lump in breast or elsewhere
e) indigestion or difficulty in swallowing

f) obvious change in wart or mole
g) nagging cough or hoarseness
6) T2NlMO indicates relatively large primary Tumor, limited to organ of origin

and 2-5 cm in size, movable nodes on same side as primary time of no
evidence of distant matastroid.

I) cervical scraping
bronchial secretions
urine sedimentation
coughed-up sputum
a mammary gland.,discharges
2) A biopsy is a surgical excision of a small piece of tissue for microscopic

examination to determine whether
..
tissue contains benign or malignant cells.
3) a) colon.
b) non-invasive
c) xerography.
d) thyroid
4) ~ u c i e a rMagnetic Resonance (NMR) identifies abnormalities without the use

of contrast dyes or radiation.

1) Advise The High Fibre food of food rich in vit A & C. Avoid smoked salt
cured nitrite cured foods avoid use of alcohol stop smoking, Pan chewing.
Check Your Progress 4 Inboductlon to
Oncology Nursing
1) Biotherapy is the use of agents called biological response mod@ers (BRM)

that modify the relationship between the host and tumor by altering the
biological response. Three categories of BRM's exist:
Agents that have direct antitumor effects
Agents that restore, augment or modulate host immune system
mechanism.
Agents that have other biological effects such as interfering with the
cancer cells ability to metastize or differentiated.
2) Synergic-where the donor and recepient are genetically identical
Allogenic-where the donor and recipient are of the same species e.g.
human to human.
Autologous-where patients own bone marrow is used following
cytotoxic therapy.
3) Metabolic infection and pain, hypercalcemia, tumor lysis syndrome, syndrome

of inappropriate anti diuretic hormone (SIADH), and disseminated
intravascular coagulation (DIC).
1) "Palliative care is the total care of patients whose disease is not responsive to
curative treatment. Control of pain, of other symptoms, and of psychological,
social and spiritual problems is paramount. The goal of palliative care is the '
achievement of the best quality of life for patient's and their families."
(World Health organization, 1990)
2) Principles of pain management (by WHO):
i) By Mouth: Oralroute is the choice of administration of analgesics and

other medications as possible.
ii) By the Clock: Analgesic medication for moderate to severe pain should
be given on a fixed dose schedule around the clock, not 'as needed'
basis.
iii) By the Ladder: The WHO has developed a three step analgesic ladder to
guide the sequential use of drugs in treating cancer pain.

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UNIT 5 INTRODUCTION TO ONCOLOGY

.e list down the warning signs of cancer;

5.2 BASIC CONCEPTS OF CANCER

5.2.1 Epidemiology of Cancer

5.2.2 Characteristics of Malignant Cell

a Malignant tumours are capable of continued growth that will compress,

5.2.3 General Classification of Neoplasms

Benign and Malignant Tumours

Classification According to Tissue of Origin

5.2.4 Etiological Factors

5.2.5 Signs and Symptoms

Any of those just mentioned above are:

5.2.6 Staging and Grading of Malignant Turnors

Methods Used for Staging

3) Pathological Staging: T~unorsize, number of sites. and degree of metastasis

I, Increasing degrees of demonstrable abnormality of regional

1) List three characteristics of cancer ceils:

2) Differentiate between benign and malignant tumours.

a) The benign tumour of fibrous tissue is ..............................

b) A benign tumour arising from the adipose tissue is called .................

c) The benign neoplasm of smooth muscle is ..............................

d) The malignant tumour of the bone is called ..............................

e) The abnormal uncontrolled multiplication of white blood cells is called

4) List the etiological factors of cancer.

5.3 COMMON DIAGNOSTIC MEASURES FOR

1) Cytologic Examination or Papanicolaou Test (Pap Smear)

Class 111 : mild to moderate dysplasia

Class IV : probably malignant

Fig. 5.1: Palpation: How to feel the lump in the breast

Mammography is a safe, simple non-invasive technique for detecting the presence

a previous breast biopsy or breast surgery,

In xerography or xeromammography, a selenium-coated plate is used and exposed

Thermography is a technique designed to locate breast

Computed Tomography (CT) also known as computerized axial tomography.

Nuclear Magnetic Resonance Imaging (NMR or MRT) identifies abnormalities

{Jltrasonography or ultrasound, uses high frequency sound waves to detect and

Place the patient in knee-chest position perfectly or in a side-lying position

ate expfanation to patient about the procedure e.g. that the

Provide some light nourishment.

12) Radioisotope Studies

be used to study the functions specific organs and tissues. For

i) Administration of the radioisotope: A tracer dose of radioisotope is given

ii) Waiting period: Tlie radioisotope needs to be assimilated by the organs

Check Your Progress 2

1) Name the specimens that can be examined by Pap smear.

2) Define biopsy in three lines.

3) Fill in the blanks,

a) Carcino embryonic antigen (CEA) test is done for diagnosis of

b) Mammography is a .................................... technique for the presence

c) Improved visualization of the breast and its structures including the

among heavy drinkers of alcohol.

following two annual examlnatlons with

. women 20 years and older as a routine good

Remember that none of these is a sure sign of cancer

alcohol beverages, and

Health teaching ldentlfrcation of Health teaching

I Health teaching / Health teaching

Cheek Your Progress 3

1) List down the preventive measures of cancer in relation to nutrition.