Disorders of Cells and Tissues (2022) PDF

**DISORDERS OF CELL AND TISSUES 45 H** **Course Content:** - Definition of terms used in Cells and Tissues disorders;  - Notions of the epidemiology of major cancers risk factors, their Screening and Prevention; - Description of Cells and Tissue Diseases; - Description of the medica...

**DISORDERS OF CELL AND TISSUES 45 H** **Course Content:** - Definition of terms used in Cells and Tissues disorders;  - Notions of the epidemiology of major cancers risk factors, their Screening and Prevention; - Description of Cells and Tissue Diseases; - Description of the medical and surgical nursing of cells and tissue disorders; -Description of nursing care related to the disease, its evolution, its treatment, the patient and the reaction of the said patient \- Description of the Prevention of biological and psychological treatment complications; \- BCC of persons with hemophilia, sickle cell, anemia; \- Management of stress and pain; \- Palliative care and support to patient in terminal phase; \- Description of the moral and ethical problems posed by care \- Description of the Clinical Pharmacology of Cells and Tissues Disorders; (Chemotherapy, anti-inflammatory analgesic opiates, steroids, clotting factors, plasma, platelets); -Description of the Mechanisms of action of Drugs and psychosocial support to patients **Outcome Objectives:** At the end of the TU the student should be able to: - Define the terms used in Cells and Tissues disorders;  - Possess good knowledge of Cells and Tissue Diseases [ ] - Cancer, the major cancers, Anemia in cancer patients, bleeding - The immune-deficient diseases - Leukemia, Hemophilia, sickle cell - Possess good knowledge of the medical and surgical nursing of cells and tissue disorders; -Possess good knowledge of nursing related to the disease, its evolution, its treatment, the patient and the reaction of the said patient \- Have good knowledge of the Prevention of biological and psychological treatment complications; \- Have good knowledge of BCC in persons with hemophilia, sickle cell, anemia \- Know how to management of stress and pain \- Have good knowledge of Palliative care and support to patient in terminal phase \- Know how to manage the moral and ethical problems posed by care Possess good knowledge of the Clinical Pharmacology of Cells and Tissues Disorders; - Chemotherapy, anti-inflammatory analgesic opiates, steroids, clotting factors, plasma, platelets; - Explain the Mechanisms of action of Drugs and psychosocial support to patients 1. BRIEFING ON CELL BIOLOGY ------------------------ 1. The Cell -------- - **Definition** The **cell** (from *Latin* *cella*, meaning \"small room\") is the basic structural, functional, and biological unit of all known living organisms. It is the smallest unit of life that can replicate independently, and they are often referred to as the \"building blocks of life\". The study of cells is called cell biology. Different types of cells in the body do different jobs, but they are basically similar. They all have a control centre called a nucleus. Inside the nucleus are chromosomes made up of long strings of DNA (deoxyribonucleic acid). DNA contains thousands of genes, which are coded messages that tell the cell how to behave.  - **Structure of the cell** Cells consist of cytoplasm enclosed within a membrane, which contains many biomolecules such as proteins and nucleic acids. Organisms can be classified as unicellular (consisting of a single cell; including bacteria) or multicellular (consisting of many cells; including plants and animals). While the number of cells in plants and animals varies from species to species, humans contain more than 10 trillion (10^13^) cells. Most plant and animal cells are visible only under a microscope, with dimensions between 1 and 100 micrometres. where genes are in cells **The Cell** Each gene is an instruction that tells the cell to make something. This could be a protein, or a different type of molecule called RNA. Together, proteins and RNA control the cell. They decide what sort of cell it will be, what it does, when it will divide, and when it will die. Tissues ------- Our bodies are made of cells, tissues, and organs with one kind of cell making one kind of tissue. For instance, only hair cells can make hair tissue, only nail cells make nail tissues only skin cells make skin tissues, only nerve cells can make nerve tissue and only sweat gland cells can make sweat gland tissue. The different kinds of tissues are classified into four groups, epithelial tissue, connective tissue, nerve tissue, and muscle tissue. **Epithelial tissues** are known to protect the body from injury and infection. This group includes the skin and the inner surfaces of the body such as the surface of the lungs, stomach, intestines, and blood vessels. - **Connective tissues** support the body and give it frame or shape. Bone, cartilage, and fatty tissue are in this group. These tissues are strong and yet usually can stretch to hold our bodies together. - **Nerve tissues** are also called **ganglia**. They are the information networks for our bodies. Nerves send information from one part of our bodies to another. They have long branching dendrites that connect one cell to another. Impulses pass along the dendrites from cell to cell as they collect information from our sensory organs or pass information to other organs. - **Muscle tissues:** Three types of muscle cells are combined to make the muscle tissue group. All of these muscle tissues act by contracting and relaxing. - **Voluntary muscle tissues**, which are striated muscle tissue. We move these muscles by choice. They are the muscles attached to our skeletons. - **Smooth muscle tissues,** which makes involuntary muscles. We do not choose to move these muscles, but they move on their own. These muscles are found inside the bodies in organs e.g cardiac muscle, smooth muscle tissue the lines internal organs like intestinal tract, blood vessel urogenital tract, respiratory tract. - **Cardiac muscle tissu**es are the third type of muscle tissues. Cardiac muscle tissue makes our hearts. 3. Organs ------ Organs is a collection of tissues that structurally form a functional unit specialized to perform a particular function eg heart, kidney, brain lungs etc Therefore, our bodies are made of cells, which make tissue, which make organs. Semiology --------- Despite dramatic advances in cancer biology and a widening array of treatment options, cancer continues to cause devastating suffering not only to hundreds of thousands of patients who die of it each year, but also to some patients who are successfully treated and become cancer survivors. Pain, depression, anxiety, fear, asthenia, blood filth and fatigue are some of the prominent factors contributing to suffering in many of these individuals. Clinical research on these symptoms holds out the hope of relief for suffering through better understanding of these symptoms and the development of new, more effective treatments and management. ### 1.4.1- Pain. Pain in cancer can be produced by mechanical (e.g. pinching compressing or infiltrating nearby body parts), from treatments and diagnostic procedures or chemical (e.g. inflammation) stimulation of specialized pain-signaling nerve endings found in most parts of the body, or it may be caused by diseased or damaged nerves, in which case it is called **neuropathic pain.** However, radiotherapy and chemotherapy may produce painful conditions that persist long after treatment has ended. It can be classified as acute (short term) or chronic (long term). The majority of patients with chronic pain notice memory lost, attention difficulties, verbal inability, mentally not flexible and thinking speed slows down. Most chronic (long-lasting) pain is caused by the illness and most acute (short-term) pain is caused by treatment or diagnostic procedures. Pain is also associated with increased depression, anxiety, fear, and anger. Persistent pain reduces function and overall quality of life, and is demoralized those who care for them. The presence of pain depends mainly on the location of the cancer and the stage of the disease. At any given time, about half of all patients with malignant cancer are experiencing pain, and two thirds of those with advanced cancer experience pain of such intensity that it adversely affects their sleep, mood, social relations and activities of daily living. However, the patient\'s description is the best measure of pain; they will usually be asked to estimate intensity on a scale of 0--10 (with 0 being no pain and 10 being the worst pain they have ever felt). With competent management, cancer pain can b**e** eliminated or well controlled in 80 to 90 percent of cases, but nearly one in two patients in the developed world receives less than optimal care. Worldwide, nearly 80 percent of people with cancer receive little or no pain medication. **Nursing a patient suffering from pain as a result of cancer** Nursing diagnoses; pain it may be related to injury agent (biological, chemical, physical or psychological) evidence by patient verbalization of pain, loss of appetite, inability to perform activities of daily living, expressive behavior ( restlessness, crying, moaning), sleep disturbance. **Desired outcome** **Patient will verbalized pain relief method** **Demonstrate the appropriate diversional activities and relaxation skills** **Display improved vital signs and muscle** ### 1.4.2- Depression Depression is a mood disorder that involves a persistent feeling of sadness and loss of interest. It's normal to grieve over the changes that cancer brings to a person's life. If a person has been sad for a long time or is having trouble carrying out day-to-day activities, that person is suffering from clinical depression. In fact, up to 1 in 4 people with cancer have clinical depression. Clinical depression causes great distress, impairs functioning, and might even make the person with cancer less able to follow their cancer treatment plan. The good news is that clinical depression can be treated. - **Symptoms of clinical depression** Some of the signs indicating that a cancer patient is suffering from clinical depression are as follows; - Ongoing sad, hopeless, or "empty" mood for most of the day - Loss of interest or pleasure in almost all activities most of the time - Major weight loss (when not dieting) or weight gain - Being slowed down or restless and agitated almost every day, enough for others to notice - Extreme tiredness (fatigue) or loss of energy - Trouble sleeping with early waking, sleeping too much, or not being able to sleep - Trouble focusing thoughts, remembering, or making decisions - Feeling guilty, worthless, or helpless - Frequent thoughts of death or suicide (not just fear of death), suicide plans or attempts Some of these symptoms, such as weight changes, fatigue, or even forgetfulness can be caused by the cancer itself and its treatment. But if 5 or more of these symptoms happen nearly every day for 2 weeks or more, or are severe enough to interfere with normal activities, it might be depression. **Nursing diagnosis** - **Nursing intervention depressed person with cancer** In order to help a clinically depressed person with cancer, it is important to; - Encourage the depressed person to continue treatment for depression until symptoms improve, or to talk to the doctor about different treatment if there's no improvement after 2 or 3 weeks. - Promote physical activity, especially mild exercise such as daily walks. - Help make appointments for mental health treatment, if needed. - Provide transportation for treatment, if needed. - Engage the person in conversation and activities they enjoy. - Remember that it's OK to feel sad and grieve over the losses that cancer has brought to their lives. - Realize that being pessimistic and thinking everything is hopeless are symptoms of depression and should get better with treatment. - Reassure the person that with time and treatment, he or she will start to feel better -- and although changes to the treatment plan are sometimes needed, it's important to be patient. - **Things not to do** - Patient should not keep feelings inside. - We should not force patient to talk when they're not ready. - Blame patient or another person for feeling depressed - Tell a person to cheer up if they seem depressed. - Try to reason with a person whose depression appears severe. Instead, talk with the doctor about medicines and other kinds of help. ### 1.4.3- Anxiety and fear It is a mental health disorder characterized by feeling of worry or fear which is strong enough to interfere with one's daily activities. At different time during treatment and recovery, people with cancer may be fearful and anxious. It might be as a result of diagnosis, reoccurrence of already treated cancer or rapid progress of the cancer. Fear of treatment, doctor visits, and tests might also cause apprehension (the feeling that something bad is going to happen). Patient may be afraid of uncontrolled pain, dying, or what happens after death, including what might happen to loved ones. And, again, these same feelings may be experienced by family members and friends. - **Signs and symptoms of fear and anxiety** - Anxious facial expressions - Uncontrolled worry - Trouble solving problems and focusing thoughts - Muscle tension (the person may also look tense or tight) - Trembling or shaking - Restlessness, may feel keyed up or on edge - Dry mouth - Irritability or angry outbursts (grouchy or short-tempered) - 1.4.4- **Panic attacks** It is a sudden episode of intense fear that triggers severe physical reaction when there is no real danger or apparent cause. Panic attacks can be an alarming symptom of anxiety. Panic attacks happen very suddenly and often reach their worst within about 10 minutes. The person may seem fine between attacks, but is usually very afraid that they will happen again. - **Symptoms of a panic attack** - Shortness of breath or a feeling of being smothered - Racing heart - Feeling dizzy, unsteady, lightheaded, or faint - Chest pain or discomfort - Feeling as if they're choking - Trembling or shaking - Sweating - Fear of losing control or "going crazy" - An urge to escape - Numbness or tingling sensations - Feeling "unreal" or "detached" from themselves - Chills (shaking or shivering) or hot flashes (may involve sweating or facial reddening) - **Nursing diagnosis anxiety** - **Anxiety** **May be related to** - **lack of knowledge regarding symptoms, progression of condition, and treatment regimen.** - **actual or perceived threat to biologic integrity.** - **unconscious conflict about essential values and goals of life.** - **Situational and maturational crises.** **Expected outcome** - Respond to [relaxation](https://nurseslabs.com/5-relaxation-tips-help-nurses-recharge-toxic-shift/) techniques with a decreased anxiety level. - Reduce own anxiety level. - Be free from anxiety attacks. **Nursing intervention** - Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available and respecting the client's use of personal space. - Remain with the client at all times when levels of anxiety are high (severe or panic); reassure client of his or her safety and security. - Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.). - Maintain calmness in your approach to the client. - Provide reassurance and comfort measures. etc ### 1.4.5- Malignancy and Fever It is well-known that cancer, diagnosed or undiagnosed, can cause fever. Indeed, fever from underlying malignancy accounts for up to 25% of cases of fever of underdetermined origin in some series. The pathophysiology of tumor-induced fever may be due to several mechanisms of which include release of cytokines from tumor cells or infiltrating mononuclear cells (e.g., tumor necrosis factor and interleukin-1); necrosis of tumoral tissue; or obstruction of a hollow duct. Other causes of fever in the cancer patient include drug fever (e.g., antibiotics, chemotherapy drugs); thrombotic thrombocytopenic purpura (TTP; which may result from chemotherapy or the tumor itself); and deep venous thrombosis. Fever is not observed in the early stage of the disease. It is mostly common in patients suffering from blood cancer like leukemia and lymphoma. **Nursing diagnosis** - [Risk for Infection](https://nurseslabs.com/risk-for-infection/) related to bone marrow suppression - Remain afebrile and achieve timely healing as appropriate. - Identify and participate in interventions to prevent/reduce risk of infection +-----------------------------------------------------------------------+ | - Promote good | | [handwashing](https://nurseslabs.com/hand-hygiene-handwashing/) | | procedures by staff and visitors. Screen and limit visitors who | | may have infections. Place in reverse isolation as indicated. | | | | - Emphasize personal hygiene. | | | | - Monitor temperature. | | | | - Assess all systems (skin, respiratory, genitourinary) for signs | | and symptoms of infection on a continual basis. | | | | - Promote adequate rest and exercise periods. | +=======================================================================+ | | +-----------------------------------------------------------------------+ ### 1.4.6- Asthenia and anorexia-cachexia Asthenia is understood as the state that includes tiredness following minimal effort, reduction of the functional capacity, feeling of weakness. Defined as feeling incapable of starting any activity in advance, reduction of concentration capacity, alteration of memory and emotional liability. Anorexia on the other hand is, defined as lack of appetite and that might result to weight loss that can accompany asthenia in these patients. Cachexia is the manifestation of undernourishment and weight loss that can be associated with asthenia, above all in the patient's final phase in PC. Up to 80% of cancer patients with advanced illness can present cachexia, due to the metabolic changes caused both by the substances secreted by the tumor and the immunological response to it. Asthenia on the other hand is the most frequent symptom in PC; it can occur in up to 90% of the cases. There are many factors involved and they can appear at different times in the same patient. The therapies that can be used may be pharmacological and non-pharmacological. Some of the factors related to asthenia in patients in palliative care include; - Pain - Anaemia - Infections - Chemotherapy and radiation therapy - Depression, insomnia and anxiety - Paraneoplastic syndromes - Cachexia - Drugs - Metabolic disorders - Associated morbidity: cardiac insufficiency, COPD, etc **1.4.7- Blood filth** Cancer and its treatments may make it more likely that patients will develop an infection. An infection occurs when bacteria, viruses, or less often, fungi (such as yeast) invade the body, but the immune system cannot stop them fast enough. Cancer treatments may weaken the immune system, increasing the chance of an infection. For example, chemotherapy lowers the number of neutrophils. Neutrophils are a type of white blood cell that helps fight infection. Common types of infections that need immediate medical attention include: - Pneumonia, which starts in the lungs - Urinary tract infection, which can start in the bladder or kidneys - Infections in the mouth, throat, esophagus, stomach, intestines, or anus However, the following symptoms of infection will require immediate care - Fever that is 100.5° F (38° C) or higher - Chest pain, or shortness of breath - Confusion - Severe headache with a stiff neck - Bloody or cloudy urine #### 1.4.7.1- Deep vein thrombosis (DVT) and pulmonary embolism (PE) - Thrombosis is a blood clot inside a blood vessel. Cancer cells damage tissue in the body, which leads to swelling and triggers clotting. Tumors also churn ( rapid release of chemicals(Aflatoxins, Aristolochic Acids, Arsenic, Asbestos, Benzene, Benzidine, Beryllium, 1,3-Butadiene) out chemical that cause clots. Some cancer like that of brain can cause blood colt than any other caner( **Cancer thickens the blood**, releasing substances that make it "sticky" so clots form more easily, and treatment can exacerbate the risk). DVT, can become life threatening if the clot travels to the lungs and causes a PE (which is a blood clot in the lung that requires a medical emergency). A PE leads to a blockage of one or more of the lung's major arteries. The signs and symptoms of DVT might be related to DVT itself or to a PE. Some people aren\'t aware of a deep vein clot until they have signs and symptoms of PE. Both DVT and PE can cause serious, possibly life-threatening problems if not treated. Signs and symptoms of a DVT may include one or more of the following: - Swelling of the leg or along a vein in the leg or arm - Pain or tenderness in the leg, which you may feel only when standing or walking - Pain or tenderness in the arm that limits movement - Increased warmth in the area of the leg or arm that\'s swollen or painful - Red or discolored skin on the leg or arms On the other hand, the signs and symptoms of a PE may include one or more of the following: - Unexplained shortness of breath - Pain in the chest, sides, or back with deep breathing - Coughing up blood - Fast breathing rate - Fast heart rate The risk of developing a DVT can be favored by factors: Surgery, chemotherapy, hormonal therapy, personal or family history of blood clotting disorders, medical conditions such as heart disease or lung disease, increased age, smoking #### 1.4.7.2- Tumour Lysis syndrome (TLS) TLS is a life-threatening medical emergency (which is a life-threatening vital organ injury). It usually occurs after chemotherapy for a fast-growing cancer, such as some types of leukemia or lymphoma. TLS is less likely to develop in people with solid tumors, with the exception of small cell lung cancer. The cause of TLS is the rapid death of cancer cells caused by cancer treatment. As tumor cells die, they break apart and spill their contents into the blood. Cell contents include potassium, phosphate, chemicals and tumor DNA. This sudden release of cell contents causes a change in certain electrolyte and other chemical concentrations in the blood, which can damage organs, including the kidneys, heart, liver and nervous system. The result can be loss of muscle control, seizures, and death. Although TLS is usually linked with chemotherapy, other types of cancer treatment may lead to TLS. Rarely, this syndrome may occur before starting any cancer treatment, and very rarely after a biopsy of a tumor. 2- Epidemiology of cancers in Cameroon ====================================== Mortality rates from all cancers combined are on the rise and it is the second most common cause of death worldwide (heart disease in the most common). In Cameroon more than 15,700 new cases are diagnosed annually. Mortality is at 10,533 deaths per year with a mortality-to-incidence ratio greater than 65%7,8. This ratio remains higher than the 60% recorded a decade ago 9, 10. In terms of incidence, women are the most affected with 9,335 new cases every year, representing a standardized risk equal to 116.9 cases per 100,000 women compared to 100.5 per 100,000 men (incidence of 6,434 new cases every year). People aged 15 and over are the most affected with 15,262 new cases. About a fifth of all cases occur in patients over the age of 65. This is mainly prostate cancer in 1,251 of the 3,495 registered cases. In terms of annual incidence, the five main cancers are: breast cancer (3,265 new cases), cervical cancer (2,349 new cases), prostate cancer (2,064 new cases), liver cancer (919 new cases) and colorectal cancers (832 new cases). In Cameroon, 43% of the population is under the age of 15 years. Pediatric cancers represent 1 to 2% of all cancers. The number of incident cases expected annually is approximately 900 new cases. In 2018, the pediatric oncology service of the Mother and Child Center of the Chantal Biya Foundation in Yaounde recorded 150 new cases of cancer. This number of cases does not reflect the reality of the situation of pediatric cancers in Cameroon, because some patients do not arrive in Yaounde for various reasons (poverty, distance, lack of diagnosis \...). In this age group, malignant hemopathies represent 50% of the cancers diagnosed. Although 90% of cancers are curable, more than 80% of patients reach an advanced stage with a high fatality rate (40%). The number of cancers continues to increase over time. The annual incidence was 12,000 cases in the year of writing of the first cancer control plan (in 2003), today it is 15,769 cases and is estimated at 27,726 cases in 2035. It will be an increase of over 75% in the current incidence if nothing is done11. In Cameroon, as in other developing countries, there is an epidemiological shift characterized by increased cases of non-communicable diseases such as cancer. Lifestyle modification (sedentary lifestyle, tobacco, and alcohol consumption...), risky local eating habits (salting, smoking, fatty meals..), the persistence of infectious diseases involved in carcinogenesis could explain this increase in the number of cancer cases. According to a WHO study, 31% of the causes of death are linked to non-communicable diseases. Breast and cervical cancer are the two most common cancers. According to the figures collected in the District Health Information System (DHIS 2), the regions with the highest number of suspected cases of breast, cervical and prostate cancer are respectively the North-West, West and Centre. ### 2.1.1- Biology of Cancer **Cancer encompasses a broad range of diseases of multiple causes that can arise in any cell of the body.** Our bodies are made up of more than a hundred million (100,000,000,000,000) cells. Cancer starts with changes in one cell or a small group of cells. Usually we have just the right number of each type of cell. This is because cells produce signals to control how much and how often the cells divide. If any of these signals are faulty or missing, cells may start to grow and multiply too much and form a lump called a tumour. Where the cancer starts is called the primary tumour. However, some types of cancer, called leukaemia, start from blood cells. They don\'t form solid tumours. Instead, the cancer cells build up in the blood and sometimes the bone marrow. There are over 100 different types of cancer, and each is classified by the type of cell that is initially affected. Tumors can grow and interfere with the digestive, nervous, and circulatory systems and they can release hormones that alter body function **Types of tumors.** There are three main types of tumour: - Benign: These are not cancerous. They are encapsulated, either cannot spread or grow, or they do so very slowly. - Premalignant: In these tumour**s**, the cells are not yet cancerous, but they have the potential to become malignant. - Malignant: Malignant tumours are cancerous More dangerous, or malignant tumors form when two things occur: - A cancerous cell manages to move throughout the body using the blood or lymphatic systems, destroying healthy tissue in a process called invasion (proliferation). - The cell manages to divide and grow, making new blood vessels to feed itself in a process called angiogenesis (differentiation). When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a serious condition that is very difficult to treat. ### 2.1.3- Pathophysiology or development of Cancer The causes and development of each type of cancer are likely to be multifactorial. It is not known how many tumours have a chemical, environmental, genetic, immunologic or viral origin. Cancers may arise spontaneously from causes that are thus far unexplained. It is a common belief that the development of cancer is a rapid and haphazard event. However, the natural history of cancer is an orderly process comprising several stages and occurring over a period of time. These stages include: initiation, promotion and progression. i. **Initiation (mutations)** The first stage, initiation is a mutation (A **mutation** is a change in a DNA sequence. **Mutations** can result from DNA copying mistakes made) in the cell's genetic structure resulting from an inherited mutation (an error that occurs during DNA replication), or following exposure to chemicals, radiology or viral agents. This is because normally genes make sure that cells grow and reproduce in an orderly and controlled way. They make sure that more cells are produced as they are needed to keep the body healthy. Sometimes a change happens in the genes when a cell divides. It means that a gene has been damaged or lost or copied twice. Some mutations mean that the cell no longer understands its instructions and starts to grow out of control or become altered. This altered cell has the potential for developing into a clone (group of identical cells) of neoplastic cells (tumour cells). There however have to be about half a dozen different mutations before a normal cell turns into a cancer cell. Mutation is irreversible, but not all altered cells go on to establish a tumour. Because many undergo apoptosis (programed cell death) it take 7-10 years for cells of the body to replace itself, neutrophil 2 days, RBC 120days. An initiation cell is not yet a tumour cell because it has not yet established the ability to self-replicate and grow. The DNA alteration may remain undetected throughout the life time of an individual unless further events stimulate development of a tumour. ii. **Promotion** A single alteration in the genetic structure of the cell is not sufficient to result in cancer. However, the ought's of cancer development are increased with the presence of promoting agents. Promotion, the second stage in the development of cancer is characterized by the reversible proliferation of altered cells. Consequently, with an increase in the altered cells population, the likely hood of additional mutation is increased. An important distinction between initiation and promotion is that the activities of promoters are reversible. This is a key concept in cancer prevention. Promoting factors include such agents as: dietary fats, obesity, cigarette smoking, and alcohol consumption. Changing a person's life style to modify these risk factors can reduce the chance of cancer development. Several promoting agents exert activities against specific types of body tissues or organs. Therefore, these agents tend to promote specific types of cancer. E.g. cigarette smoke is a promoting agent in bronchogenic carcinomas and in conjunction with alcohol intake promotes oesophageal and bladder cancers. Some carcinogens are capable of both initiating and promoting the development of cancer. These carcinogens are termed complete carcinogens e.g. cigarette smoking. iii. **Progression** This refers to the final stage in the natural history of cancer. This stage is characterized by an increased growth rate of the tumor, increased invasiveness and metastasis (that is spread of the cancer to a distant site).  **Difference between Cancer and Normal Cells** ### 2.1.4- Role of the Immune System in Cancer Formation The immune system has the potential to distinguish cells that are normal (self) from abnormal (non-self) cells. Cancer cells may display altered cells surface antigens as a result for malignant transformation. These antigens are termed tumor associated antigens (TAAs). It is believed that one of the functions of the immune system is to respond to TAAs. The response of the immune system to antigens of the malignant cells is termed **immunologic surveillance.** In this process, lymphocytes continually check cell surface antigens and detect and destroy cells with abnormal or altered antigenic determinants. It has been proposed that malignant transformation occurs continually and that the malignant cells are destroyed by immune response. Under normal circumstances, immune surveillance will prevent theses transformed cells from developing into clinically detectable tumours. ### 2.1.5- Major Cancer Risk Factors According to the International Agency for Research on Cancer (IARC), 13 risk factors for cancer have been identified. 1. Active and passive smoking 2. Ionizing radiation 3. Alcohol consumption 4. Air pollution 5. Unbalanced diet 6. Ultraviolet radiation (UV) 7. Overweight and obesity 8. Occupational exposures to carcinogens (wood dust, petroleum derivatives, chromium, tars, etc.) 9. Insufficient physical activity 10. Duration of breastfeeding less than 6 months 11. Use of exogenous hormones 12. Exposure to chemicals in the general population (arsenic, benzene) 13. Infections It is usually not possible to know exactly why one person develops cancer and another doesn't. But research has shown that certain risk factors may increase a person's chances of developing cancer. Cancer risk factors include exposure to chemicals or other substances, as well as certain behaviors. They also include things people cannot control, like age and family history. A family history of certain cancers can be a sign of a possible **inherited cancer syndrome.** The most-studied known or suspected risk factors for cancer include: aging, [alcohol](https://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol), [cancer-causing substances](https://www.cancer.gov/about-cancer/causes-prevention/risk/substances), [chronic inflammation](https://www.cancer.gov/about-cancer/causes-prevention/risk/chronic-inflammation), [diet](https://www.cancer.gov/about-cancer/causes-prevention/risk/diet), [hormones](https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones), [immunosuppression](https://www.cancer.gov/about-cancer/causes-prevention/risk/immunosuppression), [infectious agents](https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents), [obesity](https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity), [radiation](https://www.cancer.gov/about-cancer/causes-prevention/risk/radiation), [sunlight](https://www.cancer.gov/about-cancer/causes-prevention/risk/sunlight), [tobacco](https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco). Although some of these risk factors can be avoided, others such as growing older cannot. Limiting the exposure to avoidable risk factors may lower the risk of developing certain cancers. Some of the risk factors are better explained as follows; i. [**Age**](https://www.cancer.gov/about-cancer/causes-prevention/risk/age) Age is the greatest risk factor for developing cancer. In fact, 60% of people who have cancer are 65 or older. So are 60% of cancer survivors. The incidence of cancer increases with age in both humans and laboratory animals. Aging may increase or decrease the susceptibility of various tissues to initiation of carcinogenesis and usually facilitates promotion and progression of carcinogenesis. [**Alcohol**](https://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol) Drinking alcohol regularly can increase the risk of 7 different cancers. There's no 'safe' limit for alcohol when it comes to cancer, but the risk is smaller for people who drink within acceptable limits. However, no type of alcohol is better or worse than the other; it is the alcohol itself that leads to the damage, regardless of whether it is in wine, beer or spirits. Some examples of the types of cancers linked to alcohol consumption include: mouth cancer, pharyngeal cancer (upper throat), oesophageal cancer (food pipe), laryngeal cancer (voice box), breast cancer, bowel cancer and liver cancer. ii. [**Chronic Inflammation**](https://www.cancer.gov/about-cancer/causes-prevention/risk/chronic-inflammation) iii. **Hereditary cancer** - Cancer occurs at a much younger age than average - Cancer occurs in several close relatives - More than one type of cancer occurs in the same close relative - Cancer occurs in paired organs (i.e. cancer in both breasts) - Cancer occurs in more than one generation - Several rare cancers occur in a family iv. **Carcinogens** Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. These free radicals damage cells and affect their ability to function normally. v. [**Diet**](https://www.cancer.gov/about-cancer/causes-prevention/risk/diet) Dietary patterns, nutrients, and other constituents of food are major components of the environmental influences that contribute to risk for cancer. Therefore, healthy feeding and being physically active are very important for people diagnosed with cancer, both during and after cancer treatment. This is because some foods actually contribute to the development of cancer, whereas others lessen the risk. - For instance, tumor cells thrive more on low density lipoproteins (LDL's eg butter, margarine which are known to transport toxic substances from the liver back in to the circulatory system) to grow while HDL's gather toxic substances from the circulatory system back to the liver for destruction and excretion eg fish, chicken. Therefore, consuming a diet that helps to lower LDL levels could keep potential cancerous cells from growing. - Eating fat also stimulates the production of bile, which is needed to digest fat. If a lot of bile is allowed to stagnate in the large intestine for a long period of time, it's converted into apcholic acid, a proven carcinogen. Therefore, lowering fats intake, especially saturated fatty acids will lower the risk of cancer development. - Increase in fibre consumption reduces the risk of cancer development, since fibres move potential carcinogens through the intestines faster, thus decreasing the contact time between carcinogens and the intestinal wall. Besides pushing them through faster, fiber binds carcinogens, keeping them away from the intestinal wall, helping to prevent cancer (of the colon). - A diet high in antioxidants can lower cancer risk. Beta carotene, vitamin C and vitamin E which are mainly gotten from fruits and vegetables (naturally occurring antioxidants) definitely lower the risk of colorectal cancer. These antioxidants act by protecting the membrane of intestinal cells, preventing free-radical reactions that can cause bowel contents to be carcinogenic and preventing faulty metabolism in the cell, which can predispose a cell to becoming carcinogenic. **viix- [Hormones](https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones)** Our natural hormone levels change across our lifetime, especially for women, because of things like puberty, pregnancy and menopause. Also, lifestyles including drinking alcohol or being overweight, can also affect hormone levels and cancer risk. Moreover, everyone\'s body undergoes changes, some natural and some not, that can affect the way the endocrine system works. Some of the factors that affect endocrine organs include aging, certain diseases and conditions, stress, the environment, and genetics. Hormone-related cancers, namely breast, endometrium, ovary, prostate, testis, thyroid and osteosarcoma, share a unique mechanism of carcinogenesis. **Infectious risk** Despite the epidemiological transition underway in Cameroon, as in other developing countries, infectious agents remain a major risk factor. In Africa, 230,000 cases of cancer are attributable to infections, 45% by the human papillomavirus alone and 20% by the hepatitis viruses (10% for HBV and 9.6% for HCV, respectively). Helicobacter Pylori is responsible for 9% of cancers. Other viral, bacterial and parasitic agents are responsible for approximately 9% and 26.2% of cancers, respectively. In Cameroon, the number of cases of cancer attributable to infectious agents is 5191, that is, 33.6% of cancers diagnosed each year. **Exposure to radon** Radon is an ubiquitous gas on the earth's surface that is the primary source of natural exposure to radioactivity. It comes after tobacco, the second risk factor for lung cancer. The emission of radon to the atmosphere depends on the nature of the soil (granitic and volcanic regions are particularly favorable for the emanation of radon). According to the World Health Organization (WHO), the reference level of radon concentrations for the habitat is 100 Bq.m-3. In Cameroon, the uranium regions of the North (Poli) and the South (Lolodorf) have radon concentrations in homes sometimes exceeding the reference values. **Smoking Tobacco** is the primary environmental carcinogen and primary risk factor for lung cancer with a relative risk of 23.9. The prevalence of smoking is increasing in the young population. According to the Cameroon Coalition Against Tobacco, Cameroon has more than one million active smokers and about 7 million passive smokers. **Alcoholism** According to the IARC, alcohol is a proven carcinogen, its consumption increases the risk of developing cancers of the upper digestive tract, esophagus, liver and colon. The amount of pure alcohol is a real risk factor and this risk increases linearly with the dose consumed, regardless of the type of alcohol. In Cameroon, in 2016, the average consumption of pure alcohol per capita and per year was estimated at 9 liters. **Obesity** Obesity is a consequence of socioeconomic development, and the effects of changing lifestyles. Diets are more fatty, richer in alcohol and low in vegetable fibers, while populations become more sedentary. Obesity is a risk factor for breast cancer in postmenopausal women (AR = 38.8%), for colorectal (AR = 13.5%), cancers of the uterus (AR = 22.3 %), gallbladder (AR = 7.1%), pancreas (AR = 5.4%), ovaries (AR = 3.6%) and esophageal adenocarcinomas (AR = 3.2%). Obesity is an emerging problem in Cameroon. The proportion of Cameroonians who do not exercise is 27% and the prevalence of obesity is 10%16 **Genetic risk factors** Knowledge of genetic factors, whether these are predisposing genes (BRCA 1, BRCA 2 for breast cancer) or the existence of genetic polymorphisms, can make it possible to envisage screening for the population at risk in secondary prevention or to carry out some primary prevention interventions (chemo-prevention, prophylactic surgery). Colon, breast, ovarian, prostate, retinoblastoma, gliomas, medullary thyroid cancers are those for which a genetic predisposition can be found. Current studies, both epidemiological and molecular biology, indicate that a genetic risk could exist in approximately 5 to 20% of cancers. More than 200 mutations predisposing to cancer are known in humans. In Cameroon, breast cancer is the most frequent of all sexes. In young women (under 40 years) it is generally associated with a genetic predisposition, notably a mutation in the BRCA gene. In 2008, the prevalence of breast cancer among those under 40 years was estimated at 30%, which continues to increase in terms of oncology consultation statistics from general hospitals in Yaounde and Douala. However, no genetic study has been identified in this population to determine the existence of a mutation in the BRCA gene either in the patient or in their first degree relatives. No prevention and diagnostic strategy is therefore implemented for this group of the population17,18. 2.3 Managem Cancer is a public health concern in Cameroon with more than 15,700 new cases diagnosed annually, according to WHO. Cancer mortality is 10,533 deaths per year with an incidence mortality ratio greater than 65%. Adults remain the most affected population with 15,262 new cases in persons aged over 15 years. The most common cancers in adults are breast, cervical and prostate cancers. Cancer affects 1 to 2% of children. The most frequent pediatric cancers are lymphomas, acute leukemias, nephroblastomas, neuroblastomas and retinoblastomas. About 90% of patients arrive the treatment centres at advanced stages of the disease. The treatment dropout rate is estimated at 20%, and 30% of patients die after initiation of treatment. As in most developing countries, many challenges affect cancer management: the limited human resource capacity, the inaccessibility of anti-cancer drugs, the high cost of treatments, inadequate platforms as well as old infrastructure. The objective of this strategic plan is to reduce morbidity and mortality due to cancer by at least 10% in Cameroon. It presents the priority strategies and action plan over the next five years. These actions are grouped into three strategic components: primary prevention, whose objective is to reduce the incidence of cancers. It involves intenifying the actions already undertaken by the NACFAC, namely raising awareness through information and health education programs in order to encourage behavior changes. Free vaccination against Human Papilloma Virus (HPV) and Hepatitis B virus (HBV) will also be introduced nationwide in the Expanded Program on Immunization (EPI). Children born to mothers who are infected with HBV will receive the appropriate vaccine at birth. With regards to secondary prevention, emphasis will be laid on screening; interventions will include the screening and early diagnosis of cervical cancer by Visual Inspection with Acetic Acid and Lugol Iodine (VIA/VILI). Concerning case management, it will involve the upgrading of existing treatment centers and the establishment of the National Cancer Institute (NCaI) which will be the center of excellence for multidisciplinary management of cancers according to international standards. This Institute will also be a platform for the development of human resources and research in cancer. This plan also considers the basics of tertiary prevention, psychosocial support and palliative care. **Prevention of cancer** Cancer Prevention in Cameroon Cameroon does not currently have a national strategy for cancer prevention. A national strategic plan for the control of cervical cancer was drafted in 2016, but was not implemented. Among the five (5) most frequent cancers, three (3) may have an effective primary and secondary prevention strategy. These are breast cancer, cervical cancer and liver cancer. Awareness raising on modifiable risks factors With regards to primary prevention, Cameroon does not have an Integrated Communication Plan (ICP) on modifiable risks factors for cancers. However, sensitization campaigns for the general public are organized by the NACFAC during special days and events, such as during the month of October ("Octobre Rose"). Moreover, under the private initiative of civil society organizations (CSO), some sensitization campaigns are conducted within the community or professional and academic settings. These efforts do not cover the 21 2020-2024 National Strategic Plan for Prevention and Cancer Control (NSPCaPC) national territory and a large majority of Cameroonians are not yet informed and are continually exposed to risks factors of cancers. Immunization Human Papilloma Virus (HPV) In 2015, Cameroon successfully completed the pilot phase to introduce the HPV vaccine for girls aged 9 - 13 years. However, this vaccine has not yet been added into the routine EPI though it is one of the most effective strategy to reduce the incidence of cervical cancer. The MOH is planning to introduce this vaccine into the EPI in 2020. The cost of the bivalent and quadrivalent vaccine remains high for the population of Cameroon (\~XAF 35,000.00 per dose) and advocacy should be done to promote a better access for all social strata19. Hepatitis B Virus (HBV) Immunization against HBV is integrated into routine EPI. However, for children born from an infected mother, the birth dose is still borne by the family and the cost is very high. On the other hand, the national guidelines on the management of HBV exposed newborns is not avaialbale in all HFs. The promotion of HBV vaccine and the evaluation of the immunological response are not yet optimum in Cameroon. Screening Cameroon doesn't have a national screening programme for breast and cervical cancers. Some public hospitals and two (2) denominational structures, namely, the Cameroon Baptist Convention Health Services (CBCHS) and the Presbyterian Church in Cameroon Health Services (PCCHS) are doing routine screening and treatment of precancerous lessions of the cervix in some cities (Bamenda, Mbingo, Kumbo, Douala, Mutengene, Kumba, Kribi, Bafoussam, Yaounde and Limbe). Sporadic screening campaigns are organized in outreaches by the NACFAC and some CSOs. However, numerous precancerous lessions cannot be treated due to lack of equipment. Continuous screening will enable a decrease in the incidence and mortality due to cancer. Epidemiological Surveillance The epidemiological surveillance of cancers is necessary for priority decision-making in cancer control. However, this has not been effective in Cameroon since 2012, because the Yaounde cancer registery was interrupted. Nevertheless, data on suspected cases of breast, cervical and prostate cancers is documented in the DHIS-2 platform. **Screening** Cameroon doesn't have a national screening programme for breast and cervical cancers. Some public hospitals and two (2) denominational structures, namely, the Cameroon Baptist Convention Health Services (CBCHS) and the Presbyterian Church in Cameroon Health Services (PCCHS) are doing routine screening and treatment of precancerous lessions of the cervix in some cities (Bamenda, Mbingo, Kumbo, Douala, Mutengene, Kumba, Kribi, Bafoussam, Yaounde and Limbe). Sporadic screening campaigns are organized in outreaches by the NACFAC and some CSOs. However, numerous precancerous lessions cannot be treated due to lack of equipment. Continuous screening will enable a decrease in the incidence and mortality due to cancer. **Diagnosis of cancer** The diagnosis of cancer relies on a large range of clinical and para clinical arguments. It is therefore important for any health system to have laboratories for pathological, biological and biochemical analyses as well as medical imaging and nuclear medicine services. Diagnosis Pathology services The diagnosis of most cancers relies on pathological findings. Anatomo-pathology laboratories, are distributed across the country as such: 3 in public Health Facilities (Douala, Yaounde, Buea) and 3 in private structures (Bamenda, Mbingo and Bafoussam). The other regions with no pathology laboratory send them their specimens for analysis even though there is no standard sample transport system in place. In some instances the quality of the specimens are altered and this has an effect on the quality of the result. Immunohistochemistry, a technique needed for specific diagnosis and treatment is available only at the Centre Pasteur of Cameroon (CPC ) and is not affordable to most cancer patients. Moreover, the timeline for results return is long. Medical Imaging Medical imaging services are available in most HFs of category 1 to 4. Basic equipment include a standard radiograph and ultrasound equipment. The CT Scan and MRI devices recommended for investigating metastasis are available only in general and central hospitals and in 3 regional hospitals (Ebolowa, Garoua and Bafoussam). Medical imaging is thriving in the private sector but remains mostly located in the cities of Douala and Yaounde. Given that cancer is a long-term condition, patients should regularly do these medical examinations as part of their follow-up. However, the current level of affordability hinders appropraite case management. Laboratories for biological and biochemical analyses All categories 1 to 4 HFs have biological analyses laboratories which do basic medical analyses in haematology, biochemistry, bacteriology and parasitology. Apart from private laboratories, only laboratories of tertiary hospitals carry out the analysis of tumor markers for the surveillance of cancers. Molecular biology analyses are not available. Nuclear Medicine Service Cameroon does not have a functional nuclear medicine service. This service would help conduct bone scintigraphy and screen for sentinel lymph nodes, as well as metabolic radiotherapy. Positron Emission Tomography is also not available in Cameroon. ### 2.1.6- Major cancers There are said to be over 100 different types of cancer. The major types of cancer are carcinoma, sarcoma, melanoma, lymphoma, and leukemia. #### 2.1.6.1- Sarcoma Sarcomas refer to the types of cancer which arise in bone, muscle, fat, or cartilage and are relatively uncommon. Sarcomas are a rare kind of cancer and they are different from the much more common carcinomas based on the fact that they happen in a different kind of tissue. Sarcomas grow in connective tissue (cells which connect or support other kinds of tissue in your body). Although there are more than 50 types of sarcoma, they can be grouped into two main kinds: soft tissue sarcoma ( a group pf rare cancer affecting the tissues that connect, support of surround order body structures or organs eg fat, muscle blood vessels, tendons, ligament and deep skin tissue) and bone sarcoma ( a rare type of cancer that develop in bone) , or osteosarcoma. - **Sarcoma Risk Factors** The major causes of sarcoma are not yet known, but there exist some factors which raise the risk of developing one. Some of these factors include: - Family inheritance - Presence of a bone disorder one disorder called Paget\'s disease( a disease that result in to disruption in the replacement of old bone tissue with new ones. Most occurs in the pelvis, skull, spine and legs) - Presence of a genetic disorder such as neurofibromatosis ( a condition that causes tumor to form in the brain, spinal cord and nerves), Gardner syndrome(a type of polyp( abnormal tissue growth on membrane) which can be benign or malignant) or retinoblastoma - Exposure to radiation, perhaps during treatment for an earlier cancer can also predispose someone to development of sarcoma - **Symptoms** Soft tissue sarcomas are hard to spot, most often, the first sign is painless lump (that can develop in any part of the body). As the lump gets bigger, it might press against nerves or muscles, making the patient uncomfortable or giving him breathing trouble, or both. There are no tests which can be performed in order to diagnose sarcomas, but they are capable of presenting some symptoms which can help in their diagnosis. Some of which are as follows: - Osteosarcoma which can show obvious early symptoms, including: - Pain off and on in the affected bone, which may be worse at night, - Swelling, which often starts weeks after the pain - A limp (limping), if the sarcoma is in your leg - **Symptoms** The treatment of sarcoma depends on the type that has been diagnosed, where it is in the body, how developed it is, and whether or not it has spread to other parts of your body, or metastasized. Some of the methods of treatment include: surgery, use of radiation, chemotherapy and targeted therapies. **Surgery:** Surgery takes the tumor out of the body. In most cases of osteosarcoma, just the cancerous cells can be removed. In this case, there will be no need for the arm or leg removed. Most people diagnosed with a soft tissue sarcoma are cured by surgery alone, if the tumor is low-grade; that means it is not likely to spread to other parts of the body. More aggressive sarcomas are harder to treat successfully. **Radiation:** Radiation can shrink the tumor before surgery or kill cancer cells that are left after surgery. It could be the main treatment, if surgery isn\'t an option. **Chemotherapy:** Chemotherapy drugs ( alkylating agent they work directly on the DNA and RNA, fluorauracil, methotrexate, fludarabine) can also be used with or instead of surgery. Chemo is often the first treatment when the cancer has spread. Chemo can block a cell's ability to divide. But factors the determine the choice of a chemo drug are the following. - How they affect chemical substances within the cancer cell - Which activity or process in the cell can the drug interfere with - What part of the cell cycle the drug affect **Targeted therapies:** Targeted therapies are newer treatments that use drugs or manmade versions of antibodies from the immune system to block the growth of cancer cells while leaving normal cells undamaged. The survival rate for osteosarcoma is between 60% and 80% if the cancer has not spread. It is more likely to be cured if all of the cancer accumulated in such a way that they can be removed by surgery. #### 2.1.6.2- Carcinoma Carcinomas refer to the most commonly diagnosed cancers which originate in the skin, lungs, breasts, pancreas, and other organs and glands. Carcinomas start in cells that make up the skin or the tissue lining organs, such as the liver or kidneys. \"Carcinoma in situ\" stays in the cells where it started. **Types of Carcinomas** Although carcinomas can occur in many parts of the body, there exist certain common types some of which include: basal cell carcinoma, squamous cell carcinoma, renal cell carcinoma, ductal carcinoma in situ (DCIS), invasive ductal carcinoma and adenocarcinoma, a. **Basal cell carcinoma**. A type of skin cancer that most often develops on areas of skin exposed to the sun eg face. This is the most common form of all cancers. Quick treatment for basal cell carcinoma is necessary in order to avoid scars. But only in very rare cases does this type of carcinoma spread to other parts of the body. Basal cell carcinomas often look like: open sores, red patches, pink growths, shiny bumps or scars. Basal cell carcinoma can result from excessive exposure to sun. b. **Squamous cell carcinoma.** Most people think of skin cancer when they hear the words \"squamous cell carcinoma.\" And it is true that this type of carcinoma often shows up on the skin. But squamous cell carcinoma can also be found in other parts of the body, such as cells lining: certain organs, digestive tract and respiratory tract. When squamous cell carcinoma develops in the skin, it is found on areas that are exposed to the sun, such as the: cervix (thin flat cells lining the outer part of the cervix which project into the vagina) face, ears, neck, lips and backs of the hands. This type of skin cancer tends to grow and spread more than basal cell cancers. In rare cases, it may spread to the lymph nodes. Squamous cell carcinomas may crust or bleed and can include: scaly red patches, open sores, growth with a depression in the middle and warts. c. **Renal cell carcinoma**. This is the most common type of kidney cancer. It usually grows as a single tumor within the kidney. Renal cell carcinoma is sometimes discovered during a CT scan or an ultrasound which might be performed for some other reason. Sometimes it is detected after it has already become very large or spread to other organs. d. **Ductal carcinoma in situ (DCIS).** This is considered a pre-cancerous condition found in cells inside the ducts of the breast. But in DCIS, the cancer has not fully developed or spread into nearby areas. Nearly all women diagnosed with this can be cured. e. **Invasive ductal carcinoma.** This type of breast cancer starts in a milk duct but spreads into the fatty tissue of the breast. It can spread to other parts of the body through the lymph system and bloodstream. It may be discovered as a suspicious mass through a mammogram or during a breast self-exam. Other symptoms may include: - Thickening of the breast skin - Rash or redness of the breast - Swelling in one breast - New pain in one breast - Dimpling around the nipple or on breast skin - Nipple pain, nipple turning inward, or nipple discharge - Lumps in underarm area f. **Adenocarcinoma.** This is a type of carcinoma that starts in cells called \"glandular cells", which are known to be responsible for the production of mucus and other body fluids. These glandular cells are found in different organs in the body. Adenocarcinomas can occur in different parts of the body. Some examples of cancers that can be adenocarcinomas include lung, pancreatic, and colorectal, prostate etc Treatment in this case of carcinomas can be carried out by chemotherapy. #### 2.1.6.3- Melanoma Melanomas are cancers that arise in the cells that make the pigment in skin. They are known to be a form of skin cancer, amongst which we can also identify basal cell and squamous cell cancers. Melanoma develops when normal pigment-producing cells in the skin called melanocytes become abnormal, grow uncontrollably, and invade surrounding tissues. Usually only one melanoma develops at a time. Melanomas can begin in an existing mole (non-cancerous disorder of pigment producing skin cells commonly called birth marks (scar on the skin) or other skin growth, but most start in unmarked skin. - **Warning signs of skin disorders** The most important warning sign for melanoma is any change in size, shape, or color of a mole or other skin growth, such as a birthmark. The ABCDE system is often used to indicate what changes to look for, when dealing with a melanoma. - A is for asymmetry camera in which one half of the mole or skin growth doesn\'t match the other half. - B is for border irregularity camera, whereby the edges are ragged, notched, or blurred. - C is for color camera in which the color is not the same throughout the mole. - D is for diameter camera, in which the mole or skin growth is larger than the size of a pencil eraser. - E is for evolution camera, where there is a change in the size, shape, symptoms (such as itching or tenderness), surface (especially bleeding), or color of a mole. Furthermore, the signs of melanoma present in an existing mole include changes in: - Elevation, such as thickening or raising of a previously flat mole. - Surface, such as scaling, erosion, oozing, bleeding, or crusting. - Surrounding skin, such as redness, swelling, or small new patches of color around a larger lesion (satellite pigmentations). - Sensation, such as itching, tingling, burning, or pain. - Consistency, such as softening or small pieces that break off easily. - **Symptoms** During the early stages of melanoma, there might be no symptoms. Melanoma can grow anywhere on the body. It most often occurs on the upper back in men and women and on the legs in women. Less often, it can grow in other places, such as on the soles, palms, nail beds, or mucous membranes that line body cavities such as the mouth, the rectum, and the vagina. On older people, the face is the most common place for melanoma to grow. And in older men, the most common sites are the neck, scalp, and ears. Its presence may however be indicated by the development of a sore, or by itching sensations or bleed. Most melanomas start as a new skin growth on an unmarked area of the skin. The growth may then change in color, shape, or size and these changes might be early signs indicating that the growth is a melanoma. Melanoma can also develop in an existing mole or other mark on the skin. Or it may look like a bruise that isn\'t healing or show up as a brown or black streak under a fingernail or toenail. Symptoms of melanoma that has spread (metastatic melanoma) may be vague. They include swollen lymph nodes, especially in the armpit or groin, and a colorless lump or thickening under the skin. - **Treatment** Treatment of melanoma can be very complicated. Never the less, early diagnosis and treatment can increase the survival rate from melanoma. When melanoma is found early, it can often be cured by surgery during which the cancerous cells can be completely removed. But after melanoma spreads (malignant melanoma) it becomes harder to treat or cure. Patient can be placed on chemo - **Prognosis** Experts talk about prognosis in terms of \"5-year survival rates.\" The 5-year survival rate means the percentage of people who are still alive 5 years or longer after their cancer was discovered. Remember that these are only averages. Everyone\'s case is different, and these numbers don\'t necessarily show what will happen next to the patient. The estimated 5-year survival rate for melanoma is: - 98% if cancer is found early and treated before it has spread. - 62% if the cancer has spread to close-by tissue. - 15% if the cancer has spread farther away, such as to the liver, brain, or bones. #### 2.1.6.4- lymphoma Lymphomas are cancers of lymphocytes. Lymphoma is cancer that begins in infection-fighting cells of the immune system, called lymphocytes. These cells are in the lymph nodes, spleen, thymus, bone marrow, and other parts of the body. During the development of a lymphoma, lymphocytes change and grow out of control. There are two main type of lymphoid cells B ( make protein cells antibodies) and T (T cells help boost or slow the activity of other immune system cells) There are two main types of lymphoma: **Non-Hodgkin (most common) and Hodgkin**. These types of lymphomas each affect a different kind of lymphocyte. Every type of lymphoma grows at a different rate and responds differently to treatment. Lymphoma is different from leukemia. Lymphoma starts in infection-fighting lymphocytes, whereas leukemia starts in blood-forming cells inside bone marrow. Lymphoma is also not the same as lymphedema, which is a collection of fluid that forms under the skin when lymph nodes are damaged. - **Causes** The exact causes of lymphoma have not yet been discovered but in most cases it is found to develop in individuals (mostly males) as from the age of 60s or older. It also develops in males with a weak immune system from HIV/AIDS, an organ transplant, or those born with an immune disease (such as rheumatoid arthritis, lupus, or celiac disease). Furthermore, it develops in males who have been infected with a virus such as hepatitis C, human T-cell leukemia/lymphoma (HTLV-1), or humn herpesvirus 8 (HHV8). Lymphoma can also be inherited from a close relative or from exposure to benzene or chemicals that kill bugs and weeds, as well as those treated for cancer by radiation or overweight individuals. - **Symptoms** Warning signs of lymphoma include: Swollen glands (lymph nodes), often in the neck, armpit, or groin, cough, shortness of breath, fever, night sweats, stomach pain, fatigue, weight loss and itches. Many of these symptoms can also be warning signs of other illnesses. - **Treatment** Even though lymphoma is cancer, it is very treatable. Many cases can even be cured. However, the treatment obtained depends on what type of lymphoma involved and how far it has spread. The main treatments for non-Hodgkin lymphoma are: - **Chemotherapy**: Which uses drugs to kill cancer cells? - **Radiation therapy:** This uses high-energy rays to destroy cancer cells. - **Immunotherapy:** This uses the body's own immune system to attack cancer cells. Conversely, Hodgkin lymphoma can mainly be treated by chemotherapy and radiation therapy. Nevertheless, if these treatments don\'t work, a stem cell transplant might be performed. First very high doses of chemotherapy are given in order to kill some of the cancer cells. This treatment however also destroys stem cells in the bone marrow which are responsible for the synthesis of new blood cells. After chemotherapy, the transplant of the stem cells is then performed in order to replace the ones that were destroyed. Two types of stem cell transplants can be done: - An autologous transplant which uses the individual's own stem cells. - An allogeneic transplant which uses stem cells taken from a donor. - **Burkits lymphoma** Burkits lymphoma is the malignant lymphoma which originates from a specific type B lymphocyte. It is the most common childhood malignancy in many parts of Africa, particularly areas where malaria is endemic. Recurrent infections with malaria in infancy and early childhood are believed to be involved in the pathogenesis of the tumor. It is speculated that immune-suppression related to repeated attacks of malaria in early life may enable the proliferation of the malignant B lymphocytes. The majority of patients with burkits lymphoma present between the ages of 4-8years of age. This tumor is rarely seen before age 2, and less than 10% of cases occur after age 15. Burkits lymphoma is probably the fastest growing tumor in humans with a doubling time of less than 24 hours. As a result, it can rapidly lead to disfiguring swelling involving the face and abdomen. - **Clinical manifestations** About half of patients with burkits lymphoma initially present with jaw tumor- characteristically affecting the maxilla or the mandible. Loosening of teeth, particularly the molars and premolars may be the first sing of facial burkits lymphoma. As the mass enlarges the teeth become still looser or may be lost entirely. Patients with facial burkits lymphoma may also occasionally have orbital involvement. Most other patients present with increasing abdominal girth due to massive intra-abdominal swelling due either to involvement of intra-abdominal lymph nodes or to ovarian tumors. A proportion of these patients may also demonstrate flaccid paraplegia (bilateral lower extremity weakness or paralysis) resulting either from interference of blood supply to the spinal cord or from vertebral metastases. Neurologic abnormalities involving the cranial nerves may indicate more widespread metastatic disease. - **Diagnosis** The diagnosis of burkits lymphoma requires pathogenic confirmation following biopsy of the mass lesion. Alternatively, fine needle aspiration (FNA) of a suspicious mass may be performed. Fine needle aspiration (FNA) of the mass - Complete blood count with WBC differential - Abdominal ultrasound- to assess for abdominal disease, as well as to determine volume of any tumor mass found - Bone marrow aspiration for cell count and cytology- to assess for marrow involvement - Lumber puncture with CSF for cytology- to assess for CNF involvement. - **Principle of treatment and prevention of tumour lysis syndrome** As noted above, the rapid destruction of the tumour by the potent chemotherapy results in much blood-borne breakdown products. These are rich in urates and are presented to the kidneys. This condition may be fatal, therefore initial chemotherapy of a child with buckitts lymphoma must be preceded by the following preventive measures aimed at avoiding the tumour lysis syndrome. This is particularly important in the setting of a very large tumour mass. 1. Vigorous IV fluid rehydration is of paramount importance for patients who are to undergo treatment for malignancies associated with rapid tumour lysis. This is essential in order to effect an adequate diuresis prior to chemotherapy and for 3-5 days after institution of chemotherapy. Adequate urine output must be maintained prior to and following chemotherapy, during the time that tumour lysis is taking place. Implementation of an adequate diuresis is done in the following ways; - IV fluid (normal saline), one day before the first dose of cychlophophamide based on the child's age and height - In addition, oral fluids should be encouraged. The child and his carers must be given specific instructions regarding how much fluid should be consumed every hour. - It is equally important that urine output be carefully measured, using a graduated urinal bottle or another graduated container. Record urine output hourly and quantitate the total per 24 hours. It is as important to know that urine is been passed as it is for fluids to be taken. - In case where the urine output is inadequate, Lasix (furosemide) 1 mg/kg should be administered intra-venously or intramuscularly. 2. Allopurinol administration prior to delivering chemotherapy is essential in patients at risk of tumour lysis syndrome. 3. Alkalanisation of the urine with sodium bicarbonate during the first one to two days of cytotoxic treatment though not routinely done may be helpful in most severe cases. 4. In case of hypocalcaemia (serum calcium less than 8 mg/dl) an IV bolus of 5-10 cc of calcium gluconate should be given to correct this metabolic abnormality if confirmed or suspected. **2.1.6.5- Leukemia** Leukemia is usually thought of as a children's condition, but it actually affects more adults. Leukemia is a form of cancer that cannot really be prevented, since it is a form of cancer that affects the blood cells. It is caused by a rise in the number of white blood cells in the body. These white blood cells crowd out the red blood cells and platelets which are needed by the body to be healthy. All of these extra white blood cells are known to be defective in their functions in the body, and this causes problems. Leukemia is known to development as follow: Blood has three types of cells (white blood cells which fight infection; red blood cells which carry oxygen, and platelets which help blood to clot). Every day, billions of new blood cells are produced in the bone marrow most of which are red cells. But during leukemia, the body makes more of white cells than it needs. These white blood cells exist in two main types, that is lymphoid cells and myeloid cells and leukemia can happen in either type. These abnormal white blood cells are thus referred to as leukemia cells cannot fight infection the way normal white blood cells do. And because there are so many of them, they start to affect the way the major organs in the body function. Eventually, there aren't enough red blood cells to supply oxygen, enough platelets to clot the blood, or enough normal white blood cells to fight infection. Along with infection, this can cause problems like anemia, bruising, and bleeding. - **Types of Leukemia** Leukemia is grouped in two ways: - Based on how fast it develops and gets worse - Based on which type of blood cell is involved (usually myeloid or lymphoid) These types are then put into one of two categories: acute or chronic. **Acute leukemia**, happens when most of the abnormal blood cells stay immature and can't carry out normal functions. This form of leukemia is known to worsen at a very fast rate can get bad very fast. **Chronic leukemia,** which happens when there are some immature cells, but others are normal and can function normally. This type of leukemia gets bad, but more slowly. - **Causes of leukemia** The exact causes of leukemia are not yet known, but people having it have certain abnormal chromosomes, which are however not the main cause the disease. Leukemia cannot really be prevented, but it may be possible that certain environmental factors might trigger its development. For example, a tobacco smoker is more prone to some types of leukemia than a non-smoker. It's also associated with a high amount of radiation exposure, and certain chemicals. Some kinds of chemotherapy and radiation therapy used to treat other cancers can equally cause leukemia. Also, some chances of developing leukemia depend on the types of chemotherapy drugs used. Family history is another risk factor for leukemia. For example, if an identical twin gets a certain type of leukemia, there is a 20% chance the other twin will have it within a year. - **Treatment** The goal of treatment for leukemia is to destroy the leukemia cells and allow normal cells to form in your bone marrow. Treatment decisions are based on the kind of leukemia involved, its stage, as well as the age and general health of the patient. - **Treatment for acute leukemia** Most treatment plans for acute lymphoblastic leukemia (ALL) have 3 steps. These are induction, consolidation, and maintenance. Induction therapy kills leukemia cells in the blood and bone marrow to induce remission. Treatments include chemotherapy and use of corticosteroids. Induction usually lasts 4 weeks and is done in a hospital. But some people who have ALL have leukemia cells with a certain gene change. This gene is called the Philadelphia chromosome. These people will be treated with a tyrosine kinase inhibitor. Consolidation therapy kills any leukemia cells that may be present even though they don\'t show up in tests. If these cells regrow, they could cause a relapse. Treatments include more chemotherapy and may include stem cell transplant. This step may also include preventive treatment of the brain or spinal cord with radiation or chemotherapy. Consolidation usually takes several months but doesn\'t require staying overnight in the hospital. Maintenance therapy also prevents any remaining leukemia cells from growing. This may be done using lower doses of chemotherapy than those used during induction or consolidation. Chemotherapy is given with pills and once-a-month intravenous (IV) treatment. Maintenance is often continued for up to 3 years, but during this time, most people are able to go back to being as active as they were before beginning treatment. When there are no signs of leukemia for 5 years, a person is usually considered cured. But if the leukemia doesn\'t go into remission, or if it comes back within the first few years, treatments may include more chemotherapy, a stem cell transplant, or joining a clinical trial for new treatments. **Pharmacology of cancer (cytologic drugs)** **There are a number of different drugs that may be prescribed, depending on the condition. Some medications are prescribed to fight certain cancers, to prevent or treat cancer, or to control pain and relieve anxiety. Here you will find commonly used drugs in cytology. The dose of the drugs and instructions on how to take them will differ from patient to patient, depending on what the drug is being used for, patient\'s age, weight, and other considerations. Even though information about any medication may be given, we need to make sure patients fully understand the reasons for taking a medication and they need to provide information on health conditions they have. The goal of chemotherapy** may include curing the disease, decreasing tumor size, relieving symptoms, killing metastatic cells left after surgery or radiation therapy, or prolonging life. Chemotherapy is not justified unless expected benefits outweigh the potential hazards. Some commonly uses chemo drugs; Alkylating Drugs +-----------------+-----------------+-----------------+-----------------+ | Drug type | Route and | Type of cancer | Side effects | | | dosage | it treats | | +=================+=================+=================+=================+ | Chlorambucil | PO 0.1--0.2 | Chronic | Bone marrow | | (Leukeran) | mg/kg/d for | lymphocytic | depression, | | | 3--6 wk. | leukemia, | hepatotoxicity, | | | Maintenance | | | | | | Hodgkin's and | secondary | | | therapy, | non-Hodgkin's | leukemia | | | 0.03--0.1 | | | | | mg/kg/d | lymphomas | | +-----------------+-----------------+-----------------+-----------------+ | Cyclophosphamid | Induction | Hodgkin's | Bone marrow | | e | therapy, PO | disease, non- | depression, | | | 1--5 mg/kg/d; | | nausea, | | (Cytoxan) | IV | Hodgkin's | | | | | lymphomas, | vomiting, | | | 20--40 mg/kg in | | alopecia, | | | divided doses | leukemias, | hemorrhagic | | | over | cancer of | | | | | breast, | cystitis, | | | 2--5 days. | | hypersensitivit | | | Maintenance | lung or ovary, | y | | | therapy, | multiple | reactions, | | | | | | | | PO 1--5 mg/kg | myeloma, | secondary | | | daily | neuroblastoma | leukemia or | | | | | | | | | | bladder cancer | +-----------------+-----------------+-----------------+-----------------+ | Carmustine | IV 150--200 | Hodgkin's | Bone marrow | | (BiCNU, | mg/m2 every 6 | disease, non- | depression, | | | wk | | nausea, | | Gliadel) | | Hodgkin's | | | | Wafer, | lymphomas, | vomiting | | | implanted in | multiple | | | | brain after | | | | | tumor | myeloma, brain | | | | | tumors | | | | resectio | | | +-----------------+-----------------+-----------------+-----------------+ | **Antimetabolit | | | | | es** | | | | +-----------------+-----------------+-----------------+-----------------+ | Fluorouracil | IV 12 mg/kg/d | Carcinomas of | Bone marrow | | (5-FU) | for 4 d, then 6 | the breast, | depression, | | | mg/kg | | nausea, | | (Adrucil, | | colon, stomach, | | | Efudex, | every other day | and | vomiting, | | | for 4 doses | | mucositis | | Fluoroplex) | | pancreas | | | | Topical, apply | | Pain, pruritus, | | | to skin cancer | Solar | burning at site | | | lesion | keratoses, | of | | | | basal cell | | | | twice daily for | carcinoma | application | | | several weeks | | | +-----------------+-----------------+-----------------+-----------------+ | Methotrexate | (100--200 mg | Leukemias, | Bone marrow | | (MTX) | for average | non-Hodgkin's | depression, | | | adult) | | nausea, | | (Rheumatrex | | lymphomas, | | | | Acute leukemia | osteosarcoma, | vomiting, | | | in children, | | mucositis, | | | induction, | choriocarcinoma | diarrhea, | | | | of testes, | | | | PO, IV 3 | | fever, alopecia | | | mg/m2/d; | cancers of | | | | maintenance, | breast, lung, | | | | | | | | | PO 30 mg/m2 | head and neck | | | | twice weekly | | | | | | | | | | Choriocarcinoma | | | | | , | | | | | PO, IM 15 mg/m2 | | | | | | | | | | daily for 5 d | | | +-----------------+-----------------+-----------------+-----------------+ | **Antitumor | | | | | Antibiotics** | | | | +-----------------+-----------------+-----------------+-----------------+ | Bleomycin | IV, IM, SC | Squamous cell | Pulmonary | | (Blenoxane | 0.25--0.5 | carcinoma, | toxicity, | | | units/kg once | | mucositis, | | | or | Hodgkin's and | | | | | non- | alopecia, | | | twice weekly | | nausea, | | | | Hodgkin's | vomiting, | | | | lymphomas, | | | | | testicular | hypersensitivit | | | | | y | | | | carcinoma | reactions | +-----------------+-----------------+-----------------+-----------------+ | Doxorubicin | Adults, IV | Acute | Bone marrow | | conventional | 60--75 mg/m2 | leukemias, | depression, | | | every 21 d | lymphomas, | alopecia, | | (Adriamycin) | | | | | | Children, IV 30 | carcinomas of | mucositis, GI | | | mg/m2 daily for | breast, lung, | upset, | | | 3 d, | | | | | | and ovary | cardiomyopathy. | | | repeated every | | Extravasation | | | 4 wk | | | | | | | may lead to | | | | | tissue necrosis | +-----------------+-----------------+-----------------+-----------------+ | Mitomycin | IV 20 mg/m2 | Metastatic | Bone marrow | | (Mutamycin | every 6--8 wk | carcinomas of | depression, | | | | | nausea, | | | | stomach and | | | | | pancreas | vomiting. | | | | | Extravasation | | | | | may | | | | | | | | | | lead to tissue | | | | | necrosis. | +-----------------+-----------------+-----------------+-----------------+ | | | | | +-----------------+-----------------+-----------------+-----------------+ **Mechanism of action of chemo drugs** **Alkylating agents** *Alkylating agents* keep the cell from reproducing (making copies of itself) by damaging its DNA. These drugs work in all phases of the cell cycle and are used to treat many different cancers, including cancers of the lung, breast, and ovary as well as leukemia, lymphoma, Hodgkin disease, multiple myeloma, and sarcoma. Because these drugs damage DNA, they can affect the cells of the bone marrow which make new blood cells. In rare cases, this can lead to leukemia. Examples of alkylating agents include: Altretamine, Bendamustine, Busulfan, Carboplatin, Carmustine, Chlorambucil, Cisplatin, Cyclophosphamide, Dacarbazine, Ifosfamide, Lomustine, Mechlorethamine, Melphalan, Oxaliplatin, Temozolomide, Thiotepa, Trabectedin **Antimetabolites** *Antimetabolites *interfere with DNA and RNA by acting as a substitute for the normal building blocks of RNA and DNA. When this happens, the DNA cannot make copies of itself, and a cell cannot reproduce. They are commonly used to treat leukemias, cancers of the breast, ovary, and the intestinal tract, as well as other types of cancer. **Anti-tumor antibiotics** These drugs are not like the antibiotics used to treat infections. They work by changing the DNA inside cancer cells to keep them from growing and multiplying **Some commonly used anti-inflammatory in cancer care** Given its myriad pro-tumor effects, inflammation has become a target for cancer prevention and therapy. COX-2 (cyclooxygenase 2, PTGS2) is the most frequently evaluated anti-cancer anti-inflammatory target, although numerous other targets, such as NF-kB, cytokines/cytokine receptors, chemokines/chemokine receptors, FGF/FGFR (fibroblast growth factor/receptor), and VEGF have also been examined. More than two decades ago, it was demonstrated that NSAIDs (non-steroidal anti-inflammatory drugs) have anti-colon cancer effects. Other clinical trials have indicated that long-term use of aspirin or other NSAIDs decreases the incidence of colorectal, esophageal, breast, lung and bladder cancers. **corticosteroid** Corticosteroids, often simply called *steroids*, are natural hormones and hormone-like drugs that are useful in the treatment of many types of cancer, as well as other illnesses. When these drugs are used as part of cancer treatment, they are considered chemotherapy drugs. Examples of corticosteroids include: Prednisone, Methylprednisolone, Dexamethasone prednisolone is widely used in oncology. It has a marked antitumor affect in acute lymphoblastic leukemia, Hodgkin's disease and the non Hodgkins lymphoma. It has a role in the palliation of symptomatic end stage malignant disease when it may enhance appetite and produce a sense of well-being. corticosteroid are also powerful anti-suppressants. They are use to prevent organs transplant rejection. Steroids are also commonly used to help prevent nausea and vomiting caused by chemo. They are used before some types of chemo are administered to help prevent severe allergic reactions too. **Analgesics** **Analgesics(hydrocodone, codeine, oxycodone, tramadol,** Morphine, Hydromorphone (Dilaudid**) are used to relieve pain or irritation caused by many cancer. Analgesics are available either by prescription or over-the-counter and come in many dosage**), Codeine (Often used in combination with nonopioid analgesics; biotransformed, in part to morphine). Meperidine (Demerol): Not recommended in chronic cancer pain due to toxic metabolite, impaired renal function, or if receiving monoamine oxidase inhibitors **Palliative care** **Definition** Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses. It\'s best if the care can start as soon as patient is diagnosed. Care is given through all stages of the disease and treatment. **Principles of palliative care** Care is patient, family and carer centred. \... Care provided is based on assessed need. \... Patients, families and carers have access to local and networked services to meet their needs. \... Care is evidence-based, clinically and culturally safe and effective. **Care to the critically ill person** Life with cancer and cancer treatment means learning to manage symptoms and side effects. Its goal is to give the patient relief from pain and discomfort when the patient is seriously illness. - It is also called comfort care, supportive care, or symptom management. - It focuses on easing symptoms like nausea, pain, fatigue, and shortness of breath. - It helps manage stress in patient suffering from cancer by helping them handle the emotional side of the disease. - Treatments might include medicine, nutrition therapy, physical therapy, and relaxation techniques like deep breathing. - We may also offer emotional and spiritual counseling, as well as practical help to manage insurance, legal, or employment issues. - Palliative care can help guide patient on when to make decisions about treatment. - It can also help family and friends who are supporting patient during this time. **Who Gives Palliative Care?** - Pharmacists - Physical therapists - Registered dietitians - Social workers - Mental health professionals - Chaplains **Hospice care** Hospice care is support given when treatment can no longer control an illness. It's offered as patient approach the end of life usually when patient has not more than 6 months to live. Some treatments might be the same like in palliative care. But the goal is to comfort patient, not cure. If patient decide to stop cancer treatment, the health team can focus on easing the symptoms and giving him the support he need. **Stress management strategies** **Stress can speed up the spread of cancer throughout the body**, especially in ovarian, breast and colorectal cancer. When the body becomes stressed, neurotransmitters like norepinephrine are released, which stimulate cancer cells **How can cancer patients reduce stress** 1. Exercise regularly. Moderate exercise such as a 30-minute walk several times a week can help lower stress. \... 2. Spend time outside. \... 3. Schedule social activities. \... 4. Eat well. \... 5. Get plenty of sleep. \... 6. Join a support group. \... 7. Schedule daily relaxing time. \... 8. Do things you enjoy. **Behavior change communication to patients with cancer** Behavior Change Communication (BCC) is a **communication strategy which encourages individual/community to change their behavior**. It is a strategy that triggers people/society/communities to adopt healthy, beneficial and positive behavioral practices. Steps of Behaviour change communication **It involves the following steps:** 1. State program goals. 2. Involve stakeholders. 3. Identify target populations. 4. Conduct formative BCC assessments. 5. Segment target populations. 6. Define behavior change objectives. 7. Define SBCC strategy & monitoring and evaluation plan. 8. Develop communication products **Steps to Lasting Behavioral Change** Observing your own actions and their effects. Analyzing what you observe. Strategizing an action plan. Taking action. **Some examples of behavior change** - Increasing physical activity and exercise. - Improving nutrition. - Reducing drinking & Alcoholism. - Reduction in stress, anxiety, depression and sense of subjective well-being. ### 2.1.7- Hematologic Disorders Hematology is the medical study of blood and blood forming tissues**.** The word comes from the Greek word \"heme,\" meaning \"blood,\" and the suffix \"ology,\" which designates an academic field of study. Hematologists study and treat blood disorders. This includes the bone marrow, spleen and lymph system. A basic knowledge of hematology is useful in clinical settings to evaluate the patient's ability to transport oxygen and carbon dioxide, coagulate blood and combat infections. Assessment of the hematologic system is based on the patients' health history, physical examination and results of diagnostic studies. Hematologic abnormalities range from those that are asymptomatic, causing no significant impairment, to those that are symptomatic, causing significant impairment. The following are common hematologic abnormalities; anemia, bleeding, clotting factors etc. #### 2.1.7.1- Anemia The term aneamia refers to a condition in which the concentration of hemoglobin (Hb) in blood is below normal. It is a deficiency in the number of erythrocyte (red blood cells), the quantity of hemoglobin, and/or the volume of the packed RBCs (hematocrits). It is a prevalent condition with many diverse causes such as blood loss, impaired production of erythrocytes, or increased destructions of erythrocytes. Because red blood cells transport oxygen, erythrocyte disorders can lead to tissue hypoxia. This hypoxia accounts for many of the signs and symptoms of anemia. Anemia is not a specific disease but the manifestation of a pathologic process. Anemia is identified by a thorough history and physical examination and then classified by laboratory review of the complete blood count (CBC), reticulocyte count( immature red blood cell produce in the bone marrow. It takes two days for it to get mature and peripheral blood smear. Once anemia is identified, further investigations are done to determine its cause. Anemia can result from a primary hematologic problem or can develop as a secondary consequence of disease/disorders of other system. The various types of anemia can be grouped according to either a morphologic (cellular characteristic) or an etiologic (underlying cause) classification. Morphologic classification is based on the erythrocytes size and color. Etiologic classification is related to the clinical conditions causing the anemia. Although the morphologic system is the most accurate means to classifying aneamia, it is easier to discuss patients care by focusing on the etiology of the anemia. For any anaemic patient, it is of utmost importance that one seeks to discover why the patient is anaemic. In general, aneamia can be classified in one of three major ways; - Nutritional deficiencies such as iron or folate deficiency - Chronic disease (including renal, liver and endocrine disease as well as infection) - Primary disorder of the bone marrow as in leukemia and infiltration of the bone or marrow