Module 1-Cellular Aberration 1

MODULE 1. CELLULAR ABERRATIONS

Epidemiology

 Overall, the incidence of cancer is higher in men than in women and higher in
industrialized sectors and nations.
 Cancer is second only to cardiovascular disease as a leading cause of death in
the United States.
 Although the number of cancer deaths has decreased slightly, more than 560,
000 Americans were expected to die from a malignant process in 2008.
 The leading causes of cancer deaths in the United States, in order of frequency,
are lung, prostate, and colorectal cancer in men and lung, breast, and
colorectal cancer women.
 For all cancer sites combined, African American men have a 15% higher
incidence rate and a 38% higher death rate than Caucasian men.
African-American women have a 9% lower incidence rate, but an 18% higher
death rate than Caucasian women for all cancer sites combined.
 Asia accounts for nearly half of the new cancer cases and more than half of
cancer deaths.
 Estimated suggest that Asia and Africa have a higher proportion of cancer
deaths (7.3% and 57.3% respectively) compared with their incidence (5.8% and
48.4% respectively).
 The 2018 data also suggests that countries with high Human Development Index
(HDI) have 2-3 times higher cancer incidence than those with low or medium
HDI.

Pathophysiology

Cancer is a disease process that begins when an abnormal cell is transformed by the
genetic mutation of the cellular DNA.

 Proliferative patterns. Cancerous cells are described as malignant neoplasms

because they demonstrate uncontrolled cellular growth that follows no
physiologic demand (neoplasia).
 Characteristics of malignant cells. Cells are undifferentiated and often bear little
resemblance to the normal cells; they grow at the periphery and sends out
processes that infiltrate and destroy the surrounding tissues; the rate of their
growth is variable and depends on level of differentiation; they can gain access
to the blood and lymphatic channels and metastasizes to other areas of the
body; they often cause generalized effects such as anemia, weakness, and
weight loss; they often cause extensive tissue damage and causes death unless
growth can be controlled.
 Invasion and metastasis. Malignant disease processes have the ability to allow
the spread or transfer of cancerous cells from one organ or body part to another

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by invasion (growth of the primary tumor into the surrounding host tissues) and
metastasis (dissemination or spread of malignant cells from the primary tumor to
distant sites.
 Carcinogenesis. Carcinogenesis is a malignant transformation that
involves initiation (initiators such as chemicals, physical factors, and biologic
agents, escape normal enzymatic mechanisms and alter the genetic structure of
the cellular DNA), promotion (repeated exposure to co-carcinogens causes the
expression of abnormal or mutant genetics information), and progression(the
altered cells exhibit increased malignant behavior).
 Role of the immune system. Some evidence indicates that the immune system
can detect the development of malignant cells and destroy them before cell
growth becomes uncontrolled, but when the immune system fails to identify and
stop the growth of malignant cells, clinical cancer develops.

Detection and Prevention of Cancer

 Primary prevention. Primary prevention is concerned with reducing risks of

disease through health promotion strategies.
 Secondary prevention. Secondary prevention programs promote screening and
early detection activities such as breast and testicular self-examination and
Papanicolaou (Pap) tests.

Diagnosis of Cancer

 Tumor marker identification. Analysis of substances found in body tissues, blood

or other body fluids that are made by the tumor or by the body in response to
the tumor.
 Genetic profiling. Analysis for the presence of mutations in genes found in tumors
or body tissues.
 Mammography. Mammography is the use of x-ray images of the breast.
 Magnetic resonance imaging (MRI). MRI uses magnetic fields and radio-
frequency signals to create sectioned images of various body structures.
 Computed tomography (CT). CT scan uses narrow-beam x-ray to scan successive
layers of tissue for a cross-sectional view.
 Fluoroscopy. Use of X-rays that identify contrasts in the body tissue densities; may
involve the use of contrast agents.
 Ultrasonography. Ultrasound uses high-frequency sound waves echoing off body
tissues and is converted electronically into images; used to assess deep tissues
within the body.
 Endoscopy. Direct visualization of a body cavity or passageway by insertion of
an endoscope into a body cavity or opening; allows tissue biopsy,
fluid aspiration, and excision of small tumors.
 Nuclear medicine imaging. Uses intravenous injection or ingestion of
radioisotope substances followed by imaging of tissues that have concentrated
the radioisotopes.
 Positron emission tomography (PET). Through the use of a tracer, provides black
and white or color-coded images of the biologic activity of a particular area,
rather than its structure.

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 PET fusion. Use of a PET scanner and a CT scanner in one machine to provide an
image combining anatomic detail, spatial resolution, and functional metabolic
abnormalities.
 Radioimmunoconjugates. Monoclonal antibodies are labeled with a
radioisotope and injected intravenously into the patient.

Tumor Staging and Grading

Staging. Staging determines the size of the tumor and the existence of local invasion
and distant metastasis.
Tumor, nodes, and metastasis (TNM) system. The TNM system is frequently used,
where T is the extent of the primary tumor, N is the absence or presence and extent of
regional lymph node metastasis, and M is the absence or presence of distant
metastasis.

Grading. Grading refers to the classification of the tumor cells, and it seeks to define the
type of tissue from which the tumor originated and the degree to which the tumor cells
retain the functional and histologic characteristics of the tissue of origin.

Grade I to IV. Grade I tumors, also known as well-differentiated tumors, closely resemble
the tissue of origin in structure and function while Grade IV tumors do not clearly
resemble the tissue of origin in structure and function.

Management of Cancer

Treatment options offered to cancer patients should be based on treatment goals for
each specific type of cancer.

Surgery
Surgical removal of entire cancer remains the ideal and most frequently used treatment
method.

Diagnostic Surgery
1. Biopsy. Biopsy is usually performed to obtain a tissue sample for analysis of the cells
suspected to be malignant.
Types of biopsy. The three most common biopsy methods are the excisional, incisional,
and needle methods.
Excisional biopsy. Excisional biopsy is most frequently used for easily accessible tumors
of the skin, breast, and upper and lower gastrointestinal and upper respiratory tracts.
Incisional biopsy. Incisional biopsy is performed if the tumor mass is too large to be
removed.
Needle biopsy. Needle biopsies are performed to sample suspicious masses that are
easily accessible, such as growths in the breasts, thyroid, lung, liver, and kidney.

Surgery as Primary Treatment

When surgery is the primary approach in treating cancer, the goal is to remove the
entire tumor or as much as is feasible and any involved surrounding tissue, including
regional lymph nodes.

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Local excision. Local excision, often performed on an outpatient basis, is warranted

when the mass is small, and it includes removal of the mass and a small margin of
normal tissue that is easily accessible.
Wide or radical excisions. Wide excisions include removal of the primary tumor, lymph
nodes, adjacent involved structures, and surrounding tissues that may be at high risk for
tumor spread.
Video-assisted endoscopic surgery. In this minimally invasive procedure, an
endoscope with intense lighting and an attached multichip mini-camera is inserted into
the body through a small incision.
Salvage surgery. Salvage surgery is an additional treatment option that is an extensive
surgical approach to treat the local recurrence of cancer after the use of a less
extensive primary approach.
Electrosurgery. Uses electric current to destroy tumor cells.
Cryosurgery. Uses liquid nitrogen or a very cold probe to freeze tissue and cause cell
destruction.
Chemosurgery. Uses chemicals or chemotherapy applied directly to the tissue to cause
destruction.
Laser surgery. Uses light and energy aimed at an exact tissue location and depth to
vaporize cancer cells.

Photodynamic therapy. Intravenous administration of a light-sensitizing agent that is

taken up by cancer cells, followed by exposure to laser within 24-48 hours.
Radiofrequency ablation. Uses localized application of thermal energy that destroys
cancer cells through heat.

Prophylactic Surgery
Prophylactic surgery involves removing nonvital tissues or organs that are at increased
risk to develop cancer.

Examples of prophylactic surgery. Colectomy, mastectomy, and oophorectomy are

examples of prophylactic surgery.
Qualified patients. Prophylactic surgery is offered selectively to patients and discussed
thoroughly with patients and families.

Palliative Surgery
When a cure is not possible, the goals of treatment are to make the patient as
comfortable as possible.
Palliative surgery. Palliative surgery is performed in an attempt to relieve complications
of cancer.

Radiation Therapy
More than half of patients with cancer receive a form of radiation therapy at some
point during treatment.
Uses. Radiation may be used to cure cancer, as in thyroid carcinomas, localized
cancers of the head and neck, and cancers of the uterine cervix; it may control
malignant disease when a tumor cannot be removed surgically or when local nodal
metastasis is present, or it can be used neoadjuvantly.

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Types. Two types of ionizing radiation-electromagnetic radiation (xrays and gamma

rays) and particulate radiation (electrons, beta particles, protons, neutrons, and alpha
particles)- can lead to tissue disruption.

Radiation Dosage
Radiation dosage depends on the sensitivity of the target tissues to radiation, the size of
the tumor, tissue tolerance of the surrounding normal tissues, and critical structures
adjacent to the tumor target.

Lethal tumor dose. The lethal tumor dose is defined as that dose that will
eradicate 95% of the tumor yet preserve normal tissue.
Fractions. In external beam radiation, the total radiation dose is delivered over several
weeks in daily doses called fractions.
Fractionated doses. Repeated radiation treatments over time also allow for the
periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the
outside inward.

Administration of Radiation
Radiation therapy can be administered in a variety of ways depending on the source
of radiation used, the location of the tumor, and the type of cancer targeted.

Teletherapy (external beam radiation). External beam radiation therapy is the most
commonly used form of radiation, in which, depending on the size, shape, and location
of the tumor, different energy levels are generated to produce a carefully shaped
beam that will destroy the targeted tumor, yet spare the surrounding healthy tissues
and organs in an effort to reduce the treatment toxicities for the patient.
Brachytherapy (internal radiation). Internal radiation implantation, or brachytherapy,
delivers a high dose of radiation to a localized area and can be implanted by means
of needles, seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or
interstitial compartments (breast, prostate).

Toxicity
Alopecia. Altered skin integrity is a common effect and can include alopecia
or hair loss.
Stomatitis. Alterations in oral mucosa secondary to radiation therapy include stomatitis
or inflammation of the oral tissues, xerostomia or dryness of the mouth, change and loss
of taste, and increased salivation.
Thrombocytopenia. Bone marrow cells proliferate rapidly, and if sites containing bone
marrow are included in the radiation field, anemia, leukopenia, and thrombocytopenia
may result.

Nursing Management in Radiation Therapy

Assessment. The nurse assesses the patient’s skin and oropharyngeal mucosa regularly
when radiation therapy is directed to these areas, and also the nutritional status and
general well-being should be assessed.

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Symptoms. If systemic symptoms, such as weakness and fatigue, occur, the nurse
explains that these symptoms are a result of the treatment and do not represent
deterioration or progression of the disease.

Safety precautions. Safety precautions used in caring for a patient receiving

brachytherapy include assigning the patient to a private room, posting
appropriate notices about radiation safety precautions, having staff members
wear dosimeter badges, making sure that pregnant staff members are not assigned to
the patient’s care, prohibiting visits by children and pregnant visitors, limiting visits from
others to 30 minutes daily, and seeing that visitors maintain a 6 foot distance from the
radiation source.

Chemotherapy

In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells

by interfering with cellular functions, including replication.

Goal. The goal of treatment is the eradication of enough tumor so that the remaining
tumor cells can be destroyed by the body’s immune system.
Proliferating cells. Actively proliferating cells within a tumor are the most sensitive to
chemotherapeutic agents.
Nondividing cells. Nondividing cells capable of future proliferation are the least sensitive
to antineoplastic medications and consequently are potentially dangerous.
Cell cycle-specific. Cell cycle-specific agents destroy cells that are actively
reproducing by means of the cell-cycle; most affect cells in the S phase by interfering
with DNA and RNA synthesis.
Cell cycle-nonspecific. Chemotherapeutic agents that act independently of the cell
cycle phases are cell cycle nonspecific, and they usually have a prolonged effect on
cells, leading to cellular damage and death.

Antineoplastic Agents
Chemotherapeutic agents are also classified by chemical group, each with a different
mechanism of action.

 Alkylating agents. Alters DNA structure by misreading DNA code, initiating breaks
in the DNA molecule, cross-linking DNA strands
 Nitrosoureas. Similar to the alkylating agents, but they can cross the blood-brain
barrier.
 Topoisomerase I inhibitors. Induce breaks in the DNA strand by binding to
enzyme topoisomerase I, preventing cells from dividing.
 Antimetabolites. Antimetabolites interfere with the biosynthesis of metabolites or
nucleic acids necessary for RNA and DNA synthesis.
 Antitumor antibiotics. Interfere with DNA synthesis by binding DNA and prevent
RNA synthesis.
 Mitotic spindle poisons. Arrest metaphase by inhibiting mitotic tubular formation
and inhibiting DNA and protein synthesis.

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 Hormonal agents. Hormonal agents bind to hormone receptor sites that alter
cellular growth; blocks binding of estrogens to receptor sites; inhibit RNA
synthesis; suppress aromatase of P450 system, which decreases level.

Nursing Management in Chemotherapy

Nurses play an important role in assessing and managing many of the problems
experienced by patients undergoing chemotherapy.
 Assessing fluid and electrolyte balance. Anorexia, nausea, vomiting, altered
taste, mucositis, and diarrhea put patients at risk for nutritional and fluid
electrolyte disturbances.
 Modifying risks for infection and bleeding. Suppression of the bone marrow and
immune system is expected and frequently serves as a guide in determining
appropriate chemotherapy dosage but increases the risk of anemia, infection,
and bleeding disorders.
 Administering chemotherapy. The patient is observed closely during its
administration because of the risk and consequences of extravasation,
particularly of vesicant agent.
 Protecting caregivers. Nurses must be familiar with their institutional policies
regarding personal protective equipment, handling and disposal of
chemotherapeutic agents and supplies, and management of accidental spills or
exposures.

Bone Marrow Transplantation

The role of bone marrow transplantation (BMT) for malignant and some nonmalignant
diseases continues to grow.

Type of Bone Marrow Transplant

Types of BMT based on the source of donor cells include:

 Allogeneic. Allogeneic is from a related donor other than the patient; donor may
be a related donor or a matched unrelated donor.
 Autologous. Autologous BMT is from the patient himself.
 Syngeneic. Syngeneic BMT is from an identical twin.

Nursing Management in Bone Marrow Transplantation

Nursing care of patients undergoing BMT is complex and demands a high level of skill.

Implementing pre-transplantation care.

Nutritional assessments, extensive physical examinations, organ function tests, and
psychological evaluations are conducted, with blood work that includes assessing past
antigen exposure, and the patient’s support system, financial, and insurance resources
are also evaluated.

Providing care during treatment. Nursing management during bone marrow infusion or
stem cell infusions consists of monitoring the patient’s vital signs and blood oxygen
saturation; assessing for adverse effects such as fever, chills, shortness of breath,
chest pain, cutaneous reactions, nausea, vomiting, hypotension, or hypertension,

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tachycardia, anxiety, and taste changes; and providing ongoing support and patient
teaching.

Providing post transplantation care. Ongoing nursing assessments such as psychosocial

assessments in follow-up visits are essential to detect late effects of therapy after BMT,
which occur 100 days or more after the procedure, and donors also require nursing
care through being assisted in maintaining realistic expectations of themselves as well
as of the patient.
Targeted Therapies

Targeted therapies seek to minimize the negative effects on healthy tissues by

disrupting specific cancer cell functions such as malignant transformation, cell
communication pathways, processes for growth and metastasis, and genetic coding.

Biologic Response Modifiers (BRM)

Biologic response modifier therapy involves the use of naturally occurring or
recombinant agents or treatment methods that can alter the immunologic relationship
between the tumor and the host to provide a therapeutic benefit.

Nonspecific biologic response modifiers. Nonspecific agents such as Calmette-Guérin

(BCG) and Corynebacterium parvum, when injected into the patient, may serve as
antigens that can stimulate an immune response in the hopes of eradicating malignant
cells.

Monoclonal antibodies. Monoclonal antibodies (MoAbs) have become available

through technologic advances, and this type of specificity allows MoAbs to destroy the
cancer cells and spare normal cells.

Cytokines. Cytokines, substances produced by cells of the immune system to enhance

the production and functioning of components of the immune system, are also the
focus of cancer treatment research.

Retinoids. Retinoids are vitamin A derivatives that play a role in growth, reproduction,
apoptosis, epithelial cell differentiation, and immune function, wherein specific
receptors in the cell nucleus are retinoid-dependent, thus when retinoids bind with
these receptors, cell differentiation and replication are affected.

Cancer vaccines. Cancer vaccines are used to mobilize the body’s immune response
to recognize and attack cancer cells, as these cancer vaccines contain either portions
of cancer cells alone or portions of cells in combination with other substances that can
augment or boost immune responses.

Nursing Management in Biologic Response Modifier Therapy

 It is essential for the nurse to assess the need for education, support, and guidance
for both the patient and the family and assist in planning and evaluating patient
care.

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 Monitoring therapeutic and adverse effects. The nurse must be familiar with each
agent given and its potential effects, and also, the nurse must be aware of the
impact of these side effects on the patient’s quality of life.
 Promoting home and community-based care. The nurse teaches the patient and
family how to administer BRMs through subcutaneous injections, provides
instructions about side effects and helps the patient and family identify the
strategies to manage many of the common side effects of BRM therapy.

Gene Therapy
Gene therapy includes approaches that correct genetic defects or manipulate genes
to induce tumor cell destruction in the hope of preventing or combating the disease.
Challenges. One of the challenges confronting cancer gene therapy is the multiple
somatic mutations involved in the development of cancer, making it difficult to identify
the most effective gene therapy approach.

Viruses. Viruses used as vectors that transport a gene into a target cell via the cell
membrane include retroviruses, adenoviruses, vaccinia virus, fowlpox, herpes simplex
viruses, and Epstein-Barr viruses.

Approaches in Gene Therapy

Three general approaches have been used in the development of gene therapies, with
adenoviruses showing effective promise in each approach.

 Tumor-directed therapy. This is the introduction of a therapeutic gene

(suicide gene) into tumor cells in an attempt to destroy them.
 Active immunotherapy. Active immunotherapy is the administration of genes that
will invoke the antitumor responses of the immune system.
 Adoptive immunotherapy. Active immunotherapy is the administration of
genetically altered lymphocytes that are programmed to cause tumor destruction.

Complementary and Alternative Medicine

Many patients seek a more holistic or nontraditional approach, turning to
complementary and alternative therapies while continuing to utilize conventional
medicine.

Complementary and Alternative Medicine (CAM). CAM was defined as diverse

medical and health care systems, practices, and products that are not presently
considered to be part of conventional medicine.
Risk. Because of the possibility of herb-vitamin-drug interactions, there is concern about
the use of biologicals and dietary supplements, which are not regulated by the FDA nor
subjected to rigorous scientific evaluation.

Unproven and Unconventional Therapies

Hopelessness, desperation, unmet needs, lack of factual information, and family and
social pressures are major factors that motivate patients to seek unconventional
methods of treatment.
Definition. Unconventional treatments are those without scientific evidence of the ability
to cure or control cancer.

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Nursing Management in Unconventional Therapies

The most effective way to protect patients and families from fraudulent therapies and
questionable cancer cures is to establish a trusting relationship, provide supportive care,
and promote hope.
Communication. Truthful responses given in a nonjudgmental manner to questions and
inquiries about unproven methods of cancer treatments may alleviate the fear and
guilt on the part of the patient and the family that they are not “doing everything we
can” to obtain a cure.
Information. The nurse should inform the patient and family should inform the patient
and family of the characteristics common to fraudulent therapies so that they will be
informed and cautious when evaluating other forms of “therapy”.
Collaboration. The nurse should encourage the patient to inform their physicians about
the use of therapies to help prevent interactions with medications and other therapies
that may be prescribed.

Nursing Care of Patients with Cancer

Cancer Nursing Care Plans

The outlook for patients with cancer has greatly improved because of scientific and
technologic advances.

 Maintaining Tissue Integrity

Stomatitis. Assessment of the patient’s subjective experience and an objective
assessment of the oropharyngeal tissues and teeth are important and for the
treatment of oral mucositis, Palifermin (Kepivance), a synthetic form of human
keratinocyte growth factor, could be administered.
Radiation-associated skin impairment. Nursing care for patients with impaired skin
reactions includes maintaining skin integrity, cleansing the skin, promoting comfort,
reducing pain, preventing additional trauma, and preventing and managing
infection.
Alopecia. Nurses provide information about hair loss and support the patient and
family in coping with changes in body image.
Malignant skin lesions. Nursing care includes cleansing the skin, reducing superficial
bacteria, controlling bleeding, reducing odor, protecting the skin from further
trauma, and relieving pain.

 Promoting Nutrition
Anorexia. Anorexia may occur because people feel full after eating only a small
amount of food.
Malabsorption. Surgical intervention may change peristaltic patterns, later
gastrointestinal secretions, and reduce the absorptive surfaces of the
gastrointestinal mucosa, all leading to malabsorption.
Cachexia. Nurses assess patients who are at risk of altered nutritional intake so that
appropriate measures may be instituted prior to nutritional decline.

 Relieving Pain

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Assessment. The nurse assesses the patient for the source and site of pain as well as
those factors that increase the patient’s perception of pain.
Cancer pain algorithm. Various opioid and nonopioid medications may be
combined with other medications to control pain as adapted from the World

 Decreasing Fatigue
Assessment. The nurse assesses physiologic and psychological stressors that can
contribute to fatigue and uses several assessment tools such as a simple visual analog
scale to assess levels of fatigue.

 Exercise. The role of exercise as a helpful intervention has been supported by

several controlled trials.

Pharmacologic interventions. Occasionally pharmacologic interventions are utilized,

including antidepressants for patients with depression, anxiolytics for those with
anxiety, hypnotics for patients with sleep disturbances, and psychostimulants for some
patients with advanced cancer or fatigue that does not respond to any medication.
 Improving Body Image and Self-esteem
Assessment. The nurse identifies potential threats to the patient’s body image
experience, and the nurse assesses the patient’s ability to cope with the many
assaults to the body image experienced throughout the course of the disease and
treatment.
 Sexuality. Nurses who identify physiologic, psychologic or communication difficulties
related to sexuality or sexual function are in a key position to help patients seek
further specialized evaluation and intervention if necessary.
 Assisting in the Grieving Process
Assessment. The nurse assesses the patient’s psychological and mental status, as
well as the mood and emotional reaction to the results of diagnostic testing and
prognosis.
 Grieving. Grieving is a normal response to these fears and to actual or potential
losses.

Monitoring and Managing Potential Complications

 Infection. The nurse monitors laboratory studies to detect any early changes in WBC
counts.
 Septic shock. Neurologic assessments are carried out, fluid and electrolyte status is
monitored, arterial blood gas values and pulse oximetry are monitored, and IV
fluids, blood, and vasopressors are administered by the nurse.
 Bleeding and hemorrhage. The nurse may administer IL-11, which has been
approved by the FDA to prevent severe thrombocytopenia, and additional
medications may be prescribed to address bleeding due to disorders of
coagulation.
 Promoting Home and Community-Based Care
Nurses in the outpatient settings often have the responsibilities for patient teaching
and for coordinating care in the home.
 Teaching patients self-care. Follow-up visits and telephone calls from the nurse assist
in identifying problems and are often reassuring, increasing the patient’s and the
family’s comfort in dealing with complex and new aspects of care.

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Continuing care. The responsibilities of the home care include assessing the home
environment, suggesting modifications at home or in care to help the patient and the
family address the patient’s physical needs.

Prepared By: Marites A. Villar, RN