OROPHARYNGEAL OROPHARYNGEAL CANCERCANCER

Oropharyngeal cancer is a disease in which Oropharyngeal cancer is a disease in which cancer cells are found within the anatomical cancer cells are found within the anatomical borders of the oropharynx. borders of the oropharynx.

Sometimes this is called throat cancer Sometimes this is called throat cancer The majority of oropharyngeal cancers are The majority of oropharyngeal cancers are squamous cell carcinomas. squamous cell carcinomas.

Several types of cancers can Several types of cancers can start in the mouth or throatstart in the mouth or throat..

A. Squamous Cell CarcinomasA. Squamous Cell Carcinomas flat, scale-like cells that normally form the lining of the mouth flat, scale-like cells that normally form the lining of the mouth

and throatand throat B. Verrucous CarcinomaB. Verrucous Carcinoma makes up less than 5% of all oral cavity tumors. It is a low-makes up less than 5% of all oral cavity tumors. It is a low-

grade cancer that rarely spreads to other parts of the body grade cancer that rarely spreads to other parts of the body but can deeply spread into surrounding tissue.but can deeply spread into surrounding tissue.

C. Minor Salivary Gland CarcinomasC. Minor Salivary Gland Carcinomas Minor salivary gland cancers can develop in the glands that Minor salivary gland cancers can develop in the glands that

are found throughout the lining of the mouth and throatare found throughout the lining of the mouth and throat D. LymphomasD. Lymphomas tonsils and base of the tongue contain immune system tonsils and base of the tongue contain immune system

(lymphoid) tissue that can develop into a cancer(lymphoid) tissue that can develop into a cancer

Symptoms of Oropharyngeal Cancer :Symptoms of Oropharyngeal Cancer :

A sore throat that persists A sore throat that persists Pain or difficulty with swallowing Pain or difficulty with swallowing Unexplained weight loss Unexplained weight loss Voice changes Voice changes Ear pain Ear pain A lump in the back of the throat or mouth A lump in the back of the throat or mouth A lump in the neck A lump in the neck

Risk factors for Oropharyngeal Cancer :Risk factors for Oropharyngeal Cancer :

Use of alcohol Use of alcohol Use of tobacco Use of tobacco Being infected with the human papilloma Being infected with the human papilloma

virus (HPV), especially HPV-type-16 virus (HPV), especially HPV-type-16 (HPV-16) (HPV-16)

Stages of Oropharyngeal Cancer :Stages of Oropharyngeal Cancer :

Stage IStage IThe cancer is 2 centimeters or smaller and has not spread The cancer is 2 centimeters or smaller and has not spread outside the oropharynx.outside the oropharynx.

Stage IIStage IIThe cancer is larger than 2 centimeters, but not larger The cancer is larger than 2 centimeters, but not larger than 4 centimeters and has not spread outside the than 4 centimeters and has not spread outside the oropharynx.oropharynx.

Stage IIIStage IIIIn this stage, cancer is larger than 4 centimeters and has In this stage, cancer is larger than 4 centimeters and has not spread outside the oropharynx. An alternate form of not spread outside the oropharynx. An alternate form of this stage is that cancer is any size and has spread to this stage is that cancer is any size and has spread to only one lymph node on the same side of the neck as the only one lymph node on the same side of the neck as the cancer. The lymph node that contains cancer is 3 cancer. The lymph node that contains cancer is 3 centimeters or smaller.centimeters or smaller.

Stage IVStage IVThis stage contains the sub-stages of IVA, IVB and IVC.This stage contains the sub-stages of IVA, IVB and IVC.

Stage IVAStage IVAIn Stage IVA, one of the following is the case:In Stage IVA, one of the following is the case:

The cancer has spread to tissues near the oropharynx, including the The cancer has spread to tissues near the oropharynx, including the voice box, roof of the mouth, jaw, muscle of the tongue, or central voice box, roof of the mouth, jaw, muscle of the tongue, or central muscles of the jaw. The cancer might have spread to one or more nearby muscles of the jaw. The cancer might have spread to one or more nearby lymph nodes, which are still not larger than 6 centimeters. lymph nodes, which are still not larger than 6 centimeters.

The cancer is any size, is only in the oropharynx, and has spread to one The cancer is any size, is only in the oropharynx, and has spread to one lymph node that is larger than 3 centimeters but no larger than 6 lymph node that is larger than 3 centimeters but no larger than 6 centimeters, or to more than one lymph node, none larger than 6 centimeters, or to more than one lymph node, none larger than 6 centimeters. centimeters.

Stage IVBStage IVBIn Stage IVB, one of the following is true:In Stage IVB, one of the following is true:

The cancer appears in a lymph node that is larger than 6 centimeters and The cancer appears in a lymph node that is larger than 6 centimeters and might have spread to other tissues around the oropharynx. might have spread to other tissues around the oropharynx.

The cancer surrounds the main artery in the neck or has spread to bones The cancer surrounds the main artery in the neck or has spread to bones in the jaw or skull, to muscle in the side of the jaw, or to the upper part of in the jaw or skull, to muscle in the side of the jaw, or to the upper part of the throat behind the nose. The cancer might have spread to nearby the throat behind the nose. The cancer might have spread to nearby lymph nodes. lymph nodes.

Stage IVCStage IVCIn Stage IVC, the cancer has spread to other parts of the body. The In Stage IVC, the cancer has spread to other parts of the body. The tumor might be any size and might have spread to lymph nodes.tumor might be any size and might have spread to lymph nodes.

Treatment by stage:Treatment by stage: Stage I - Stage I - Treatment might be radiation therapy or surgery.Treatment might be radiation therapy or surgery. Stage II - Stage II - Treatment involves surgery to remove the cancer or Treatment involves surgery to remove the cancer or

radiation therapy.radiation therapy. Stage III - Stage III - Treatment for this stage of oropharyngeal cancer might Treatment for this stage of oropharyngeal cancer might

include surgery to remove the cancer, followed by radiation therapy.include surgery to remove the cancer, followed by radiation therapy. Other treatments might include:Other treatments might include: Radiation therapy alone Radiation therapy alone A clinical trial of chemotherapy that is followed by surgery or A clinical trial of chemotherapy that is followed by surgery or

radiation therapy radiation therapy A clinical trial of chemotherapy combined with radiation therapy A clinical trial of chemotherapy combined with radiation therapy A clinical trial of new ways to provide radiation therapy A clinical trial of new ways to provide radiation therapy Stage IV - Stage IV - For cases in which oropharyngeal cancer can be removed For cases in which oropharyngeal cancer can be removed

by surgery, treatment might be one of the following:by surgery, treatment might be one of the following: Surgery to remove the cancer that is followed by radiation therapy Surgery to remove the cancer that is followed by radiation therapy Radiation therapy alone Radiation therapy alone A clinical trial combining radiation therapy and chemotherapy A clinical trial combining radiation therapy and chemotherapy A clinical trial of new ways to provide radiation therapy A clinical trial of new ways to provide radiation therapy

For cases in which the cancer cannot be removed For cases in which the cancer cannot be removed by surgery, treatment might include one of the by surgery, treatment might include one of the following:following:

Radiation therapy Radiation therapy A clinical trial during which chemotherapy is A clinical trial during which chemotherapy is

followed by surgery or radiation therapy followed by surgery or radiation therapy A clinical trial of radiation therapy given with A clinical trial of radiation therapy given with

chemotherapy or radiosensitizers (drugs to make chemotherapy or radiosensitizers (drugs to make the cancer cells more sensitive to radiation the cancer cells more sensitive to radiation therapy) therapy)

A clinical trial of new ways of giving radiation A clinical trial of new ways of giving radiation therapy therapy

A clinical trial of hyperthermia therapy plus A clinical trial of hyperthermia therapy plus radiation therapy radiation therapy

Nursing AssessmentNursing Assessment Obtain complete history, noting risk factors such as Obtain complete history, noting risk factors such as

smoking and alcohol use.smoking and alcohol use. Question the patient regarding changes in Question the patient regarding changes in

swallowing, smell or taste, salivation, discomfort swallowing, smell or taste, salivation, discomfort when eating, sore throat, foul breath odor.when eating, sore throat, foul breath odor.

Note the quality of voice patterns and odor of breath.Note the quality of voice patterns and odor of breath. Inspect the oral cavity: erythema, red velvety areas; Inspect the oral cavity: erythema, red velvety areas;

white patches; bleeding; swelling; record the size, white patches; bleeding; swelling; record the size, location, and description.location, and description.

Palpate the cervical lymph nodes for size, firmness, Palpate the cervical lymph nodes for size, firmness, or tenderness.or tenderness.

Nursing Diagnoses:Nursing Diagnoses: Pain related to malignant infiltration, Pain related to malignant infiltration,

lesion(s), difficulty swallowing, surgery, lesion(s), difficulty swallowing, surgery, radiation therapyradiation therapy

Altered Nutrition: Less Requirements Altered Nutrition: Less Requirements related to pain, difficulty in chewing or related to pain, difficulty in chewing or swallowing, history of Alcohol abuse.swallowing, history of Alcohol abuse.

Body Image Disturbance related to Body Image Disturbance related to changes in facial contour, cosmetic defect changes in facial contour, cosmetic defect from surgery.from surgery.

Nursing Interventions:Nursing Interventions: A. Achieving an Acceptable Level of ComfortA. Achieving an Acceptable Level of Comfort 1. Provide systemic analgesics or analgesics gargles as prescribed.1. Provide systemic analgesics or analgesics gargles as prescribed. 2. If the patient can tolerate it, provide mouth care with soft toothbrush and 2. If the patient can tolerate it, provide mouth care with soft toothbrush and

flossing between teeth.flossing between teeth. 3. If patient cannot tolerate brushing and flossing:3. If patient cannot tolerate brushing and flossing:

a. Gently lavage oral cavity with a catheter inserted between the patient’s cheek a. Gently lavage oral cavity with a catheter inserted between the patient’s cheek and gums with warm water and mouthwash.and gums with warm water and mouthwash.

b.Use power water spray to clean inaccessible areas if patient’s comfort b.Use power water spray to clean inaccessible areas if patient’s comfort allows.allows.

4. Encourage use of mouthwashes that do not contain alcohol, which may 4. Encourage use of mouthwashes that do not contain alcohol, which may irritate the gums.irritate the gums.

5. Provide management of decreased salivation, if necessary.5. Provide management of decreased salivation, if necessary. a. Insert a gauze wick in corner of mouth; place basin conveniently to catch a. Insert a gauze wick in corner of mouth; place basin conveniently to catch

drooling; replace frequently to absorb and direct excess saliva.drooling; replace frequently to absorb and direct excess saliva. b. Suction secretions with a soft rubber catheter as needed; instruct patient on b. Suction secretions with a soft rubber catheter as needed; instruct patient on

suctioning methods.suctioning methods. 6. Provide management of decreased salivation, if necessary6. Provide management of decreased salivation, if necessary

a. Encourage intake of fluids, if not contraindicated.a. Encourage intake of fluids, if not contraindicated. b. Instruct the patient to avoid dry, bulky, and irritating foodb. Instruct the patient to avoid dry, bulky, and irritating food c. Offer lemon lozenges or chewing gum to stimulate salivation.c. Offer lemon lozenges or chewing gum to stimulate salivation.

B. Improving Nutritional statusB. Improving Nutritional status A. Handle feeding problems in one or a combination of the A. Handle feeding problems in one or a combination of the

following ways, as ordered: Intravenously, Nasogastric Tube following ways, as ordered: Intravenously, Nasogastric Tube Feedings or gastrostomy tube feedings, OrallyFeedings or gastrostomy tube feedings, Orally

B. Provide mouth care before and after eatingB. Provide mouth care before and after eating C. Allow the patient to have meals in privacy, if desired.C. Allow the patient to have meals in privacy, if desired. D. Offer easily chewed foods, mash or blenderize, if necessary.D. Offer easily chewed foods, mash or blenderize, if necessary.

C. Strengthening Body ImageC. Strengthening Body Image 1. Allow verbalization of fears, anger and distaste with 1. Allow verbalization of fears, anger and distaste with

body changes in a non defensive manner.body changes in a non defensive manner. 2. Communicate acceptance of appearance in an 2. Communicate acceptance of appearance in an

honest manner.honest manner. 3. Encourage the family and friends to visit so patient is 3. Encourage the family and friends to visit so patient is

aware that others care about him or her.aware that others care about him or her. 4. Provide diversional activities.4. Provide diversional activities.

LARYNGEAL CANCERLARYNGEAL CANCER

Cancer of the larynx also may be Cancer of the larynx also may be called laryngeal cancer. It can develop in called laryngeal cancer. It can develop in any part of the larynx. Most cancers of any part of the larynx. Most cancers of the larynx begin in the glottis. The inner the larynx begin in the glottis. The inner walls of the larynx are lined with cells walls of the larynx are lined with cells called squamous cells. Almost all called squamous cells. Almost all laryngeal cancers begin in these cells. laryngeal cancers begin in these cells. These cancers are called squamous cell These cancers are called squamous cell carcinomas.carcinomas.

SymptomsSymptoms

Hoarseness or other voice changes Hoarseness or other voice changes A lump in the neck A lump in the neck A sore throat or feeling that something is stuck A sore throat or feeling that something is stuck

in your throat in your throat A cough that does not go away A cough that does not go away Problems breathing Problems breathing Bad breath Bad breath An earache An earache Weight lossWeight loss

DiagnosisDiagnosis

Indirect laryngoscopyIndirect laryngoscopy Physical examPhysical exam Direct laryngoscopyDirect laryngoscopy CT scanCT scan BiopsyBiopsy

TreatmentTreatment

Radiation therapyRadiation therapy SurgerySurgery ChemotherapyChemotherapy

STOMACH CANCERSTOMACH CANCER

Gastric cancer: Cancer of the Gastric cancer: Cancer of the stomach, the major organ that holds food stomach, the major organ that holds food for digestion. Most stomach cancers for digestion. Most stomach cancers begin in Inner layer or lining (mucosa). begin in Inner layer or lining (mucosa).

SymptomsSymptoms

Symptoms of a more advanced stomach cancer can include:Symptoms of a more advanced stomach cancer can include: Loss of appetite Loss of appetite Weight loss Weight loss Fluid in the abdomen Fluid in the abdomen Blood in the stool Blood in the stool AnaemiaAnaemia Early symptoms can include:Early symptoms can include: Indigestion, acidity and burping Indigestion, acidity and burping Feeling full Feeling full Pain or discomfort in the upper abdomen Pain or discomfort in the upper abdomen Feeling or being sick Feeling or being sick Difficulty in swallowing Difficulty in swallowing Bleeding or tiredness and breathlessness because you have lost blood Bleeding or tiredness and breathlessness because you have lost blood Blood clotsBlood clots

diagnosis diagnosis

Upper endoscopyUpper endoscopy Stomach X-ray (barium upper GI series)Stomach X-ray (barium upper GI series) Endoscopic ultrasoundEndoscopic ultrasound Computerized tomography (CT) scanComputerized tomography (CT) scan Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI) Chest X-rayChest X-ray LaparoscopyLaparoscopy Blood testsBlood tests

TreatmentTreatment

SurgerySurgery Radiation therapy (also called Radiation therapy (also called

radiotherapy)radiotherapy) ChemotherapyChemotherapy Drug therapyDrug therapy Clinical trialsClinical trials

BREAST CANCERBREAST CANCERCancers occur when abnormal cells grow in Cancers occur when abnormal cells grow in an uncontrolled way. Almost all breast an uncontrolled way. Almost all breast cancers occur in women - very few occur in cancers occur in women - very few occur in men.men.The cancer usually begins as a small lump in The cancer usually begins as a small lump in a breast and then grows, either slowly or a breast and then grows, either slowly or quickly.quickly.It can also spread to other parts of the body It can also spread to other parts of the body after a period of time. Early diagnosis is the after a period of time. Early diagnosis is the key to survival.key to survival.

AnatomyAnatomy

The female breast consists of a core made The female breast consists of a core made up of lobules (milk glands) and ducts. This core up of lobules (milk glands) and ducts. This core is surrounded by a layer of fat, and overlying this is surrounded by a layer of fat, and overlying this is skin. Milk is produced on the lobules or milk is skin. Milk is produced on the lobules or milk glands and collects in small ducts called terminal glands and collects in small ducts called terminal ducts. These terminal duct join together to form ducts. These terminal duct join together to form larger ducts, which drain, via the nipple.larger ducts, which drain, via the nipple.

Each female breast has about 12 to 15 breast Each female breast has about 12 to 15 breast lobules. This understanding of breast anatomy is lobules. This understanding of breast anatomy is important because breast lump including cancer important because breast lump including cancer develop mostly within the milk ducts and glands.develop mostly within the milk ducts and glands.

Risk FactorsRisk FactorsAgeAge

Personal history of Breast cancerPersonal history of Breast cancer

Family historyFamily history

Certain breast changesCertain breast changes

Gene changes (BRCA1, BRCA2)Gene changes (BRCA1, BRCA2)

Reproductive and menstrual historyReproductive and menstrual history

RaceRace

Radiation therapy to the chestRadiation therapy to the chest

Breast densityBreast density

Taking DES (diethylstilbestrol)Taking DES (diethylstilbestrol)

Being overweight or obese after menopause Being overweight or obese after menopause

Lack of physical activity Lack of physical activity

Drinking alcohol Drinking alcohol

Clinical ManifestationsClinical ManifestationsCommon symptoms of breast cancer include:Common symptoms of breast cancer include:

A change in how the breast or nipple feelsA change in how the breast or nipple feelsA lump or thickening in or near the breast or in the A lump or thickening in or near the breast or in the underarm areaunderarm area(Nipple tenderness)(Nipple tenderness)A change in how the breast or nipple looksA change in how the breast or nipple looksA change in the size or shape of the breastA change in the size or shape of the breastA nipple turned inward into the breastA nipple turned inward into the breastThe skin of the breast, areola, or nipple may be scaly, The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.looks like the skin of an orange.Nipple discharge (fluid) Nipple discharge (fluid) Early breast cancer usually does not cause pain. Early breast cancer usually does not cause pain.

DiagnosisDiagnosisClinical breast examClinical breast examDiagnostic mammogramDiagnostic mammogramUltrasoundUltrasoundMagnetic resonance imagingMagnetic resonance imagingBiopsyBiopsyFine-needle aspiration Fine-needle aspiration Core biopsy Core biopsy Surgical biopsySurgical biopsy

StagingStagingStage 0Stage 0 - Carcinoma in situ - Carcinoma in situ Stage IStage I - Tumor (T) does not involve axillary lymph - Tumor (T) does not involve axillary lymph

nodes (N). nodes (N). Stage IIAStage IIA – T 2-5 cm, N negative, or T <2 cm and N – T 2-5 cm, N negative, or T <2 cm and N

positive. positive. Stage IIBStage IIB – T > 5 cm, N negative, or T 2-5 cm and N – T > 5 cm, N negative, or T 2-5 cm and N

positive (< 4 axillary nodes). positive (< 4 axillary nodes). Stage IIIAStage IIIA – T > 5 cm, N positive, or T 2-5 cm with 4 or – T > 5 cm, N positive, or T 2-5 cm with 4 or

more axillary nodes more axillary nodes Stage IIIBStage IIIB – T has penetrated chest wall or skin, and – T has penetrated chest wall or skin, and

may have spread to < 10 axillary N may have spread to < 10 axillary N Stage IIICStage IIIC – T has > 10 axillary N, 1 or more – T has > 10 axillary N, 1 or more

supraclavicular or infraclavicular N, or internal mammary supraclavicular or infraclavicular N, or internal mammary N. N. Stage IVStage IV – Distant metastasis (M) – Distant metastasis (M)

TreatmentTreatmentSurgerySurgery: Removal of the lump (called a lumpectomy) is the preferred : Removal of the lump (called a lumpectomy) is the preferred technique. Removal of lymph nodes in the armpit may be undertaken technique. Removal of lymph nodes in the armpit may be undertaken as well. Removal of the breast (called a mastectomy) is only as well. Removal of the breast (called a mastectomy) is only performed if absolutely necessary.performed if absolutely necessary.

ChemotherapyChemotherapy: Medicines that interfere with cancer cell growth and : Medicines that interfere with cancer cell growth and division are administered to reduce the size of tumours or kill them.division are administered to reduce the size of tumours or kill them.

Hormonal therapyHormonal therapy: Hormones are chemical signals which are : Hormones are chemical signals which are released by different parts of the body and can carried in the blood to released by different parts of the body and can carried in the blood to some other area to have an effect. Oestrogen is a sex hormone that some other area to have an effect. Oestrogen is a sex hormone that promotes the growth of some breast cancers. Hormonal treatments, promotes the growth of some breast cancers. Hormonal treatments, such as anti-oestrogens, aromatase inhibitors or LHRH analogues, such as anti-oestrogens, aromatase inhibitors or LHRH analogues, are designed to block the effects of oestrogen or its production, are designed to block the effects of oestrogen or its production, which stops or slows the growth of cancer cells.which stops or slows the growth of cancer cells.

Radiation therapyRadiation therapy: X-rays or other high-energy rays are applied to : X-rays or other high-energy rays are applied to the tumour and surrounding areas to destroy cancer cells.the tumour and surrounding areas to destroy cancer cells.

PrognosisPrognosisThere are several prognostic factors associated with There are several prognostic factors associated with

breast cancer. Stage is the most important, as it takes into breast cancer. Stage is the most important, as it takes into consideration local involvement, lymph node status and consideration local involvement, lymph node status and whether metastatic disease is present. The higher the stage at whether metastatic disease is present. The higher the stage at diagnosis, the worse the prognosis. Breast cancer patients diagnosis, the worse the prognosis. Breast cancer patients whose lymph nodes are cancer-free have a much better whose lymph nodes are cancer-free have a much better prognosis than those whose lymph nodes are positive for prognosis than those whose lymph nodes are positive for cancer.cancer.

The presence of estrogen and progesterone receptors The presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor which in the cancer cell is another important prognostic factor which may guide treatment. Hormone receptor positive breast cancer may guide treatment. Hormone receptor positive breast cancer is usually associated with much better prognosis compared to is usually associated with much better prognosis compared to hormone negative breast cancer.hormone negative breast cancer.

HER2/neu status has also been described as a HER2/neu status has also been described as a prognostic factor. Patients whose cancer cells are positive for prognostic factor. Patients whose cancer cells are positive for HER2/neu have more aggressive disease and may be treated HER2/neu have more aggressive disease and may be treated with trastuzumab, a monoclonal antibody that targets this with trastuzumab, a monoclonal antibody that targets this protein.protein.

ManagementManagement

Treatment methodsTreatment methods

Local therapyLocal therapy: Surgery and radiation therapy are local treatments. : Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.to control the disease in those specific areas.

Systemic therapySystemic therapy: Chemotherapy, hormone therapy, and biological : Chemotherapy, hormone therapy, and biological therapy are systemic treatments. They enter the bloodstream and therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.Systemic treatments also are used for cancer that has spread.

SurgerySurgery

Breast-sparing surgery:Breast-sparing surgery: An operation to remove the cancer but not An operation to remove the cancer but not the breast is breast-sparing surgery. It is also called breast-the breast is breast-sparing surgery. It is also called breast-conserving surgery, lumpectomy, segmental mastectomy, and conserving surgery, lumpectomy, segmental mastectomy, and partial mastectomy. Sometimes an excisional biopsy serves as partial mastectomy. Sometimes an excisional biopsy serves as a lumpectomy because the surgeon removes the whole lump.a lumpectomy because the surgeon removes the whole lump.

MastectomyMastectomy: An operation to remove the breast (or as much of : An operation to remove the breast (or as much of

the breast tissue as possible) is a mastectomy. In most cases, the breast tissue as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm. Some the surgeon also removes lymph nodes under the arm. Some women have radiation therapy after surgery.women have radiation therapy after surgery.

Sentinel lymph node biopsySentinel lymph node biopsy is a new method of checking for is a new method of checking for cancer cells in the lymph nodes. A surgeon removes fewer cancer cells in the lymph nodes. A surgeon removes fewer lymph nodes, which causes fewer side effects. (If the doctor lymph nodes, which causes fewer side effects. (If the doctor finds cancer cells in the axillary lymph nodes, an axillary lymph finds cancer cells in the axillary lymph nodes, an axillary lymph node dissection usually is done.)node dissection usually is done.)

Radiation therapyRadiation therapy

External radiationExternal radiation: The radiation comes from a large : The radiation comes from a large machine outside the body. Most women go to a machine outside the body. Most women go to a hospital or clinic for treatment. Treatments are usually hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.5 days a week for several weeks.

Internal radiationInternal radiation (implant radiation): Thin plastic tubes (implant radiation): Thin plastic tubes (implants) that hold a radioactive substance are put (implants) that hold a radioactive substance are put directly in the breast. The implants stay in place for directly in the breast. The implants stay in place for several days. A woman stays in the hospital while she several days. A woman stays in the hospital while she has implants. Doctors remove the implants before she has implants. Doctors remove the implants before she goes home.goes home.

ChemotherapyChemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given as a pill or by injection of drugs. The drugs may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.bloodstream and travel throughout the body.

Blood cellsBlood cells: These cells fight infection, help your blood to : These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, some women have tired. Years after chemotherapy, some women have developed leukemia (cancer of the blood cells).developed leukemia (cancer of the blood cells).

Hormone therapyHormone therapy

DrugsDrugs: Your doctor may suggest a drug that can : Your doctor may suggest a drug that can block the natural hormone. One drug is block the natural hormone. One drug is tamoxifen, which blocks estrogen. Another type tamoxifen, which blocks estrogen. Another type of drug prevents the body from making the of drug prevents the body from making the female hormone estradiol. Estradiol is a form of female hormone estradiol. Estradiol is a form of estrogen. This type of drug is an aromatase estrogen. This type of drug is an aromatase inhibitor. If you have not gone through inhibitor. If you have not gone through menopause, your doctor may give you a drug menopause, your doctor may give you a drug that stops the ovaries from making estrogen.that stops the ovaries from making estrogen.

Biological therapyBiological therapy

Biological therapy helps the immune system fight Biological therapy helps the immune system fight cancer. The immune system is the body's natural cancer. The immune system is the body's natural defense against disease.defense against disease.Some women with breast cancer that has spread Some women with breast cancer that has spread receive a biological therapy called Herceptin® receive a biological therapy called Herceptin® (trastuzumab). It is a monoclonal antibody. It is made (trastuzumab). It is a monoclonal antibody. It is made in the laboratory and binds to cancer cells.in the laboratory and binds to cancer cells.Herceptin is given to women whose lab tests show Herceptin is given to women whose lab tests show that a breast tumor has too much of a specific protein that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, it can slow or known as HER2. By blocking HER2, it can slow or stop the growth of the cancer cells.stop the growth of the cancer cells.

Radiological InvestigationsRadiological Investigations

MRI of Breast Ultrasound Mammotome

Ultrasonography Digital Mammography

Lung CancerLung Cancer Lung cancer is leading cancer killer Lung cancer is leading cancer killer

among men and women in the United among men and women in the United StAtes.In 2005, there were an estimated StAtes.In 2005, there were an estimated 172,500 new case of the lung and 172,500 new case of the lung and bronchus (93,000 men and 79,500 bronchus (93,000 men and 79,500 women). women).

PathophysiologyPathophysiology Between 80% and 90% of lung cancers are caused by Between 80% and 90% of lung cancers are caused by

inhaled carcinogens, most commonly cigarette smokersinhaled carcinogens, most commonly cigarette smokers other carcinogens include radon gas and occupational other carcinogens include radon gas and occupational

and environmental agents. and environmental agents. Lung cancers arise from a single transformed epithelial Lung cancers arise from a single transformed epithelial

cell in the tracheobronchial airways, in which the cell in the tracheobronchial airways, in which the carcinogen binds to and damages the cell’s DNA.this carcinogen binds to and damages the cell’s DNA.this damage results in cellular changes, abnormal cell growth, damage results in cellular changes, abnormal cell growth, and eventually a malignant cell. As the damaged DNA is and eventually a malignant cell. As the damaged DNA is passed on to daughter cells, the DNA undergoes further passed on to daughter cells, the DNA undergoes further changes and becomes unstable. With the accumulation of changes and becomes unstable. With the accumulation of genetic changes, the pulmonary epithelium undergoes genetic changes, the pulmonary epithelium undergoes malignant transformation from normal epithelium malignant transformation from normal epithelium undergoes malignant transformation from normal undergoes malignant transformation from normal epithelium eventually to invasive carcinoma. Evidence epithelium eventually to invasive carcinoma. Evidence indicates that carcinoma tends to arise at of sites of indicates that carcinoma tends to arise at of sites of previous scarring (TB, fibrosis) in the lung.previous scarring (TB, fibrosis) in the lung.

Risk FactorsRisk Factors Tobacco SmokeTobacco Smoke

Tobacco use is responsible for more than one of every six Tobacco use is responsible for more than one of every six deaths in the United States from pulmonary and cardiovascular deaths in the United States from pulmonary and cardiovascular diseases. Smoking is the most important single preventable cause diseases. Smoking is the most important single preventable cause of death and disease in this country .lung cancer is 10 times more of death and disease in this country .lung cancer is 10 times more common in cigarette smokers than nonsmokers. Risk is common in cigarette smokers than nonsmokers. Risk is determined by the pack- year history (number of packs of determined by the pack- year history (number of packs of cigarette used each day, multiplied by the number of years cigarette used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. The risk of cancer is always the risk of developing lung cancer. The risk of cancer is always higher for former smokers than for people who have never higher for former smokers than for people who have never smoked. However, the risk decreases beginning at approximately smoked. However, the risk decreases beginning at approximately 5 years after smoking cessation occurs and continues to decrease 5 years after smoking cessation occurs and continues to decrease over time.over time.

SecondhandSecondhand

Passive smoking has been identified Passive smoking has been identified as a possible cause of lung cancer in as a possible cause of lung cancer in nonsmokers. It is estimated that nonsmokers. It is estimated that secondhand smoke causes about 3000 secondhand smoke causes about 3000 deaths per year (Baldwin, 2003). When deaths per year (Baldwin, 2003). When compared with unexposed to tobacco compared with unexposed to tobacco smoke in a closed environment ( house, smoke in a closed environment ( house, automobile,buiding) have an increased risk automobile,buiding) have an increased risk of lung cancer.of lung cancer.

Environmental and Occupational ExposureEnvironmental and Occupational ExposureVarious carcinogens have been identified in Various carcinogens have been identified in

the atmosphere,including mototr vehicle the atmosphere,including mototr vehicle emissions and pollutants from refineries and emissions and pollutants from refineries and manufacturing plants.Evidence suggests that the manufacturing plants.Evidence suggests that the incidence of lung cancer is greater in urban areas incidence of lung cancer is greater in urban areas as a result of the buildup of pollutants and motor as a result of the buildup of pollutants and motor vehicle emissionsvehicle emissions

Radon is colors, odorless gas found in soil Radon is colors, odorless gas found in soil and rocks. For many years it has been associated and rocks. For many years it has been associated with the development of lung cancer, especially with the development of lung cancer, especially when combined with cigarette smoking. when combined with cigarette smoking. Homeowners are advised to have radon levels Homeowners are advised to have radon levels checked in their houses and to arrange for checked in their houses and to arrange for special venting if the levels are high.special venting if the levels are high.

GeneticsGenetics Some familial predisposition to lung cancer seems apparent, because Some familial predisposition to lung cancer seems apparent, because

the incidence of lung cancer in close relatives of patients with lung the incidence of lung cancer in close relatives of patients with lung cancer appears to be two to three times that in the general population cancer appears to be two to three times that in the general population regardless of smoking status.regardless of smoking status.

Dietary FactorsDietary Factors Smokers who eat a diet low in fruits and vegetables have an Smokers who eat a diet low in fruits and vegetables have an

increased brisk of developing lung cancer. the actual active agents in increased brisk of developing lung cancer. the actual active agents in a diet rich in fruits and vegetables a diet rich in fruits and vegetables

Have yet to be determined. It has been hypothesized that carotenoids, Have yet to be determined. It has been hypothesized that carotenoids, particularlyparticularly

Carotene or vitamin A may be important. Several ongoing trials may Carotene or vitamin A may be important. Several ongoing trials may help determine whether carotene supplementation has anticancer help determine whether carotene supplementation has anticancer properties. Other nutrients, including vitamin E, selenium, vitamin C properties. Other nutrients, including vitamin E, selenium, vitamin C fat, and retinoids are alsobeing evaluated regarding their protective fat, and retinoids are alsobeing evaluated regarding their protective role against lung cancer.role against lung cancer.

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS Often lung cancer develops insidiously and is asymptomatic until late in its Often lung cancer develops insidiously and is asymptomatic until late in its

course. the signs and symptoms depend on the location and size of the course. the signs and symptoms depend on the location and size of the tumor, the degree of obstruction, and the existence of metastases to regional tumor, the degree of obstruction, and the existence of metastases to regional or distant sites. The most frequent symptom of lung cancer is cough, without or distant sites. The most frequent symptom of lung cancer is cough, without sputum production. When obstruction of airways occurs, the cough may sputum production. When obstruction of airways occurs, the cough may become productive due to infection. Dyspnea occurs in 35% to 50% of become productive due to infection. Dyspnea occurs in 35% to 50% of patients (Baldwin, 2003). Hemoptysis or blood tinged sputum may be patients (Baldwin, 2003). Hemoptysis or blood tinged sputum may be expectorated. Chest or shoulder pain may indicateexpectorated. Chest or shoulder pain may indicate

Chest wall or pleural involvement by a tumor. Pain also is a late manifestation Chest wall or pleural involvement by a tumor. Pain also is a late manifestation and may be related to metastasis to the bone. In some patient, a recurring and may be related to metastasis to the bone. In some patient, a recurring fever is an early symptom in response to a persistent infection in an area of fever is an early symptom in response to a persistent infection in an area of pneumonitis distal to the tumor. In fact,cancer of the lung should be pneumonitis distal to the tumor. In fact,cancer of the lung should be suspected in people with repeated unresolved upper respiratory tract suspected in people with repeated unresolved upper respiratory tract infections.if the tumor spreads to adjacent structures and regional lymph infections.if the tumor spreads to adjacent structures and regional lymph nodes,the patient may present with chest pain and tightness, nodes,the patient may present with chest pain and tightness, hoarseness(involving the recurrent laryngeal nerve).dysphagia, head and hoarseness(involving the recurrent laryngeal nerve).dysphagia, head and neck edema, and symptoms of pleural or pericardial effusion. The most neck edema, and symptoms of pleural or pericardial effusion. The most common sites of metastases are lymph nodes, bone, brain,contralateral lung, common sites of metastases are lymph nodes, bone, brain,contralateral lung, adrenal glands,and liver.Nonspecific symptoms of weakness,anorexia,and adrenal glands,and liver.Nonspecific symptoms of weakness,anorexia,and weight loss also may be present.weight loss also may be present.

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings If pulmonary symptoms occur in heavy smokers, cancer If pulmonary symptoms occur in heavy smokers, cancer

of the lung should always be considered chest x-ray is of the lung should always be considered chest x-ray is performed to search for pulmonary density, a solitary performed to search for pulmonary density, a solitary pulmonary nodule (coin lesion), atelectasis, and infection. pulmonary nodule (coin lesion), atelectasis, and infection. CT scans of the chest are used x-ray and also to serially CT scans of the chest are used x-ray and also to serially examine areas for lymphadenopathy.sputum cytology is examine areas for lymphadenopathy.sputum cytology is rarely used to make a diagnosis of lung cancer.Fiberoptic rarely used to make a diagnosis of lung cancer.Fiberoptic bronchoscopy is more commonly used; it provides a bronchoscopy is more commonly used; it provides a detailed study of the tracheobronchial tree and allow for detailed study of the tracheobronchial tree and allow for brushings, washings, and amenable to bronchoscopic brushings, washings, and amenable to bronchoscopic biopsy, a transthoracic fine- needle aspiration may be biopsy, a transthoracic fine- needle aspiration may be performed under CT guidance to aspirate cells from a performed under CT guidance to aspirate cells from a suspicious area. In some circumstances, an endoscopy suspicious area. In some circumstances, an endoscopy with esophageal ultrasound may be used to obtain a with esophageal ultrasound may be used to obtain a transesophageal biopsy of enlarged subcarinal lymph transesophageal biopsy of enlarged subcarinal lymph nodes that are not easily accessible by others means.nodes that are not easily accessible by others means.

Medical ManagementMedical Management The objective of management is to provide a The objective of management is to provide a

cure, if possible. Treatment depends on the cell cure, if possible. Treatment depends on the cell type, the stage of the disease, and the patient’s type, the stage of the disease, and the patient’s physiologic status (particularly cardiac and physiologic status (particularly cardiac and pulmonary status).In general,treatment m may pulmonary status).In general,treatment m may involve surgery,radiation therapy, or involve surgery,radiation therapy, or chemotherapy—or a combination of chemotherapy—or a combination of these.Newer and more specific therapies to these.Newer and more specific therapies to modulate the immune system(gene therapy, modulate the immune system(gene therapy, therapy wiyh defined tumor antigens) are under therapy wiyh defined tumor antigens) are under study and show promise.study and show promise.

Surgical ManagementSurgical Management Surgical resection is the preferred method of treating Surgical resection is the preferred method of treating

patients with localized non-small cell tumors, no evidence of patients with localized non-small cell tumors, no evidence of metastatic spread, and adequate cardiopulmonary function. metastatic spread, and adequate cardiopulmonary function. If the patient’s cardiovascular status are safisfactory, If the patient’s cardiovascular status are safisfactory, surgery is generally well tolerated. However, coronary artery surgery is generally well tolerated. However, coronary artery disease, pulmonary insufficiency, and other comorbidities disease, pulmonary insufficiency, and other comorbidities may contraindicate surgical intervention. The cure rate of may contraindicate surgical intervention. The cure rate of surgical resection depends on the type and stage of the surgical resection depends on the type and stage of the cancer surgery is primarily used for NSCLCs, because cancer surgery is primarily used for NSCLCs, because small cell cancer of the lung grow rapidly and metastasizes small cell cancer of the lung grow rapidly and metastasizes early and extensively. Lesons of many patients with early and extensively. Lesons of many patients with bronchogenic cancer are inoperable at the of diagnosis. bronchogenic cancer are inoperable at the of diagnosis.

Several different types of lung resection may be performed Several different types of lung resection may be performed (chart 23-9). The most common surgical procedure for a (chart 23-9). The most common surgical procedure for a small, apparently curable tumor of the lung is lobectomy small, apparently curable tumor of the lung is lobectomy ( removal of a lobe of the lung). In some cases, an entire ( removal of a lobe of the lung). In some cases, an entire lung may be removed lung may be removed

Radiation TherapyRadiation Therapy Radiation therapy may offer cure in a small percentage of patients. It Radiation therapy may offer cure in a small percentage of patients. It

is useful in controlling neoplasm that cannot be surgically resected is useful in controlling neoplasm that cannot be surgically resected but are responsive to radiation. Irradiation also may be used to reduse but are responsive to radiation. Irradiation also may be used to reduse the size of a tumor,to make an inoperable, or to relieve the pressure of the size of a tumor,to make an inoperable, or to relieve the pressure of the tumor on vital structures. It can reduce symptoms of spinal cord the tumor on vital structures. It can reduce symptoms of spinal cord metastasis and superior vena caval compression. Also, Prophylactic metastasis and superior vena caval compression. Also, Prophylactic brain irradiation is use in certain patients to treat microscopic brain irradiation is use in certain patients to treat microscopic metastases to the brain. Radiation therapy may help relieve metastases to the brain. Radiation therapy may help relieve cough,chest pain, dyspnea, hemoptysis ands bone and liver pain. cough,chest pain, dyspnea, hemoptysis ands bone and liver pain. Relief of symptoms may last in improving the quality of the remaining Relief of symptoms may last in improving the quality of the remaining period of life. Radioatoin therapy usually is toxic to normal tissue period of life. Radioatoin therapy usually is toxic to normal tissue within the radiation field, and this may lead to complicationssuch as within the radiation field, and this may lead to complicationssuch as esophaitis, pneumonitis, and radiation lung fibrosis. These may impair esophaitis, pneumonitis, and radiation lung fibrosis. These may impair ventilatory and diffusion cacacity and significantly redurce pulmonary ventilatory and diffusion cacacity and significantly redurce pulmonary reserve. The patient’s nutritional status, psychological outlook, fatigue reserve. The patient’s nutritional status, psychological outlook, fatigue level, and signs of anemia and infection are monitored throughout the level, and signs of anemia and infection are monitored throughout the treatment. See chapter 16 for management of the patient receiving treatment. See chapter 16 for management of the patient receiving radiation therapy.radiation therapy.

ChemotherapyChemotherapy CHEMOTHERAPY is used to alter tumor growth CHEMOTHERAPY is used to alter tumor growth

patterns, to treat distant metastases or small cell patterns, to treat distant metastases or small cell cancer of the lung, and as an adjunct to surgery or cancer of the lung, and as an adjunct to surgery or radiation therapy. Chemotherapy may provide radiation therapy. Chemotherapy may provide relief, especially of pain, but it does not usually relief, especially of pain, but it does not usually cure the disease or prolong life to any great cure the disease or prolong life to any great degree. Chemotherapy is also accompanied by degree. Chemotherapy is also accompanied by side effects. It is valuable in reducing pressure side effects. It is valuable in reducing pressure symptoms of lung cancer and in treating brain symptoms of lung cancer and in treating brain spinal cord and pericardial metastasis. See spinal cord and pericardial metastasis. See chapter 16 for a discussion of chemotherapy for chapter 16 for a discussion of chemotherapy for the patients with cancer.the patients with cancer.

Palliative TherapyPalliative Therapy

Palliative therapy may include radiation therapy Palliative therapy may include radiation therapy to shrink the tumor to provide pain relief, a to shrink the tumor to provide pain relief, a varierty of bronchoscopic interventions to open varierty of bronchoscopic interventions to open a narrowed bronchus or airway, and pain a narrowed bronchus or airway, and pain management and other comfort measures. management and other comfort measures. Evaluation and referral for hospice care are Evaluation and referral for hospice care are important in planning for comfortable and important in planning for comfortable and dignified end –of –life care for the patients and dignified end –of –life care for the patients and family.family.

Nursing managementNursing management

Nursing care of patients with lung cancer Nursing care of patients with lung cancer is similar to that for other patients with is similar to that for other patients with cancer (see Chapter 16 ) and addresses cancer (see Chapter 16 ) and addresses the physiology and psychological needs the physiology and psychological needs of the respiratory manifestations of the of the respiratory manifestations of the disease. Nursing care includes straregies disease. Nursing care includes straregies to ensure relief of pain and discomfort to ensure relief of pain and discomfort and to prevent complications.and to prevent complications.

Managing SymptomManaging Symptom

The nurse instructs the patient and family The nurse instructs the patient and family about the potential side effects of the about the potential side effects of the specific treatment and strategies to specific treatment and strategies to manage them. Strategies for managing manage them. Strategies for managing such symptoms as dyspnea, fatigue, such symptoms as dyspnea, fatigue, nausea and vomiting, and anorexia help nausea and vomiting, and anorexia help the patient and family cope with the patient and family cope with therapeutic measures. therapeutic measures.

Relieving Breathing ProblemsRelieving Breathing Problems

Airway clearance techniques are key maintaining airway patency Airway clearance techniques are key maintaining airway patency through the removal of excess secretion. This may be through the removal of excess secretion. This may be accomplished through deep-breathing exercises, chest accomplished through deep-breathing exercises, chest physiotherapy, directed cough.sunctioning, and in some instance physiotherapy, directed cough.sunctioning, and in some instance bronchoscopy. Bronchodilator medications may be prescribed to bronchoscopy. Bronchodilator medications may be prescribed to promote bronchial dilation. As the tumor enlarges or spreads,promote bronchial dilation. As the tumor enlarges or spreads,

it may compress a bronchus or involve a large area of lung tissue, it may compress a bronchus or involve a large area of lung tissue, resulting in an impaired breathing pattern and poor gas exchange. resulting in an impaired breathing pattern and poor gas exchange. At some stage of the disease, supplement oxygen will probably be At some stage of the disease, supplement oxygen will probably be necessary.necessary.

Nursing measures focus on decreasing dyspnea by encouraging Nursing measures focus on decreasing dyspnea by encouraging the patient to assume positions that promote lung expansion and the patient to assume positions that promote lung expansion and relaxation. Patient education about energy conservation and relaxation. Patient education about energy conservation and airway clearance techniques is also necessary. Many of the airway clearance techniques is also necessary. Many of the techniques used in pulmonary rehabilitation can be applied to techniques used in pulmonary rehabilitation can be applied to patients with lung cancer, Depending on the severity of disease patients with lung cancer, Depending on the severity of disease and the patient's wishes, a referral to a pulmonary rehabilitation and the patient's wishes, a referral to a pulmonary rehabilitation program may be helpful in managing respiratory symptoms.program may be helpful in managing respiratory symptoms.

Reducing FatigueReducing Fatigue

Fatigue is a devastating symptom that affect quality of life in Fatigue is a devastating symptom that affect quality of life in patients with cancer, it is commonly experienced by patients patients with cancer, it is commonly experienced by patients cancer and may be related to the disease itsefl, the cancer cancer and may be related to the disease itsefl, the cancer treatment and complication (eg, anemia), nutrition, or the treatment and complication (eg, anemia), nutrition, or the psychological ramifications of the disease (eg, anxiety, psychological ramifications of the disease (eg, anxiety, depression). The nurse is pivotal in thoroughly assessing the depression). The nurse is pivotal in thoroughly assessing the patient's level of fatigue, identifying potentially treatable causes, patient's level of fatigue, identifying potentially treatable causes, and validating with the patient that fatigue is indeed an important and validating with the patient that fatigue is indeed an important symptom. Educating the patient about energy conservation symptom. Educating the patient about energy conservation techniques or referral to physical therapy, occupational therapy, or techniques or referral to physical therapy, occupational therapy, or pulmonary rehabilitation program may be helpful. In addition, pulmonary rehabilitation program may be helpful. In addition, guided exercise has been recently identified as a potential guided exercise has been recently identified as a potential intervention for treating fatigue in cancer patients. This is an intervention for treating fatigue in cancer patients. This is an important area for research, because few studies have been important area for research, because few studies have been conducted, and only in select populations of patients with cancer.conducted, and only in select populations of patients with cancer.

Providing Psychological Providing Psychological SupportSupport

Another important part of the nursing care of patients Another important part of the nursing care of patients with lung cancer is provision of psychological support with lung cancer is provision of psychological support and identification of potential resources for the patient and identification of potential resources for the patient and family. Often, the nurse must help the patient and and family. Often, the nurse must help the patient and family deal with the following:family deal with the following:

The poor prognosis and relatively rapid progression of The poor prognosis and relatively rapid progression of this diseasethis disease

Informed decision making regarding the possible Informed decision making regarding the possible treatment optionstreatment options

Method to maintain the patient’s quality of life during Method to maintain the patient’s quality of life during the course of this diseasethe course of this disease

End-of-life treatment optionEnd-of-life treatment option