Nursing Care of Patients With Cancer PDF

4068_Ch11_171-201 15/11/14 1:21 PM Page 171 11 Nursing Care of Patients With Cancer LUCY L. COLO AND JANICE L. BRADFORD LEARNING OUTCOMES 1. Explain the normal structures and functions of the cell. 2. Describe changes that occur in a cell when it becomes malignant. 3. Identify commonly used chemot...

4068_Ch11_171-201 15/11/14 1:21 PM Page 171 11 Nursing Care of Patients With Cancer LUCY L. COLO AND JANICE L. BRADFORD LEARNING OUTCOMES 1. Explain the normal structures and functions of the cell. 2. Describe changes that occur in a cell when it becomes malignant. 3. Identify commonly used chemotherapeutic agents. 4. Discuss the special nursing needs of the patient receiving chemotherapy or radiation therapy. 5. Identify data to collect when caring for a patient with cancer. 6. Recognize common oncological emergencies and related nursing care. 7. Discuss how you will know if your nursing interventions have been effective. 8. Describe the role of hospice in providing care for patients with advanced cancer. KEY TERMS alopecia (AL-oh-PEE-she-ah) anemia (uh-NEE-mee-yah) anorexia (AN-oh-REK-see-ah) benign (bee-NINE) biopsy (BY-opp-see) cancer (KAN-sir) carcinogen (kar-SIN-oh-jen) chemotherapy (KEE-moh-THAIR-uh-pee) contact inhibition (kon-takt in-huh-BIH-shun) cytotoxic (SY-toh-TOCK-sik) desquamation (dee-skwa-MAY-shun) in situ (in-SY-too) leukopenia (LOO-koh-PEE-nee-ah) malignant (muh-LIG-nunt) metastasis (muh-TASS-tuh-sis) mucositis (MYOO-koh-SY-tis) nadir (NAY-dur) neoplasm (NEE-oh-PLAZ-uhm) neutropenia (noo-troh-PEE-nee-ah) oncology (on-CAW-luh-gee) oncovirus (ON-koh-VY-russ) palliation (pal-ee-AY-shun) radiation therapy (RAY-dee-AY-shun THAIR-uh-pee) stomatitis (STOH-mah-TY-tis) thrombocytopenia (THROM-boh-SY-toh-PEE-nee-ah) tumor (TOO-merr) vesicant (VESS-ih-kent) xerostomia (ZEE-roh-STOH-mee-ah) 171 4068_Ch11_171-201 15/11/14 1:21 PM Page 172 UNIT TWO 172 Understanding Health and Illness as the hemoglobin of red blood cells (RBCs). Important functional proteins are the enzymes that catalyze the specific reactions characteristic of each type of cell. REVIEW OF NORMAL ANATOMY AND PHYSIOLOGY OF CELLS Cells are the smallest living structural and functional subunits of the body. Although human cells vary in size, shape, and certain metabolic activities, they have many characteristics in common. Cell Structure Human cells have a plasma membrane, c ytoplasm (cytosol, organelles), and a nucleus (Fig. 11.1). Organelles are specific in structure and function. Variations in the relative amounts of organelles and cell features allow great diversity in cells, and therefore in tissues. Nucleus The nucleus of a cell is its control center , containing the individual’s unique deoxyribonucleic acid (DN A) sequence (Fig. 11.2). Most cells ha ve one central nucleus, although variations exist. DNA coding regions are called genes; a gene is the code for one protein. Not all of the genes in a particular cell are active, only those needed for the proteins required to carry out their specific functions. These proteins may be structural, such as the collagen of connective tissue, or functional, such Golgi apparatus Genetic Code and Protein Synthesis The genetic code of DNA is the code for the amino acid sequences needed to synthesize a cell’s proteins. The assembly of amino acids into the primary structure of a protein is a twostep process: transcription and translation. Transcription makes a copy of the code needed for a protein so DN A can remain guarded in the nucleus. Translation occurs at the ribosome where the nucleotide code of nucleic acids is translated into the amino acid code of protein (see Fig. 11.3). As with any complex process, mistakes are possible. If there is a mistak e in the DNA code, the process of protein synthesis may continue, b ut the resulting protein will not function normally; this is the basis for genetic diseases. DNA mistakes acquired during life are called mutations. A mutation is any change in the DNA code. Ultraviolet rays or exposure to certain chemicals may cause structural changes in the DNA code. These changes can kill the af fected cells or may irreversibly alter their function. Such altered cells can become malignant, being unable to function normally. These cells actively replicate the mutated DNA during division, creating a mass of faulty cells. This is the basis of some forms Centriole Mitochondrion Smooth endoplasmic reticulum Rough endoplasmic reticulum Plasma membrane: The boundary of the cell Cilia Nucleus: The center of the cell Nuclear envelope Nuclear pores Nucleolus Vacuole Microfilaments Cytoplasm: A gel-like substance surrounding the nucleus and packed with various organelles and molecules, each of which serves a specific function Microtubules Lysosome FIGURE 11.1 Schematic of a typical human cell. From Thompson, G. C. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 38. 4068_Ch11_171-201 15/11/14 1:21 PM Page 173 Chapter 11 Nursing Care of Patients With Cancer 173 A double-layered membrane called the nuclear envelope surrounds the nucleus. Perforating the nuclear envelope are nuclear pores. These pores regulate the passage of molecules into the nucleus (such as those needed for construction of RNA and DNA), as well as out of the nucleus (such as RNA, which leaves the nucleus to perform its work in the cytoplasm). Ribosomes Extending throughout the nucleoplasm (the substance filling the nucleus) are thread-like structures composed of DNA and protein called chromatin. When a cell begins to divide, the chromatin coils tightly into short, rod-like structures called chromosomes. Endoplasmic reticulum (attached to nucleus) In the center of the nucleus is the nucleolus. The nucleolus manufactures components of ribosomes, the cell’s protein producing structures. FIGURE 11.2 The nucleus. From Thompson, G. C. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 40. DNA mRNA double helix strand G U A C U G A T C Transcription T C G A 1 When the nucleus receives a chemical message to make a new protein, the segment of DNA with the relevant gene unwinds. 2 An RNA enzyme then assembles RNA nucleotides that would be complementary to the exposed bases. The nucleotides attach to the exposed DNA and then bind to each other to form a strand of messenger RNA (mRNA). This strand is an exact copy of the opposite side of the DNA molecule. G T G A C A C T C T G C T G U G A C A C U C U A G C T C A C T G T G A G 3 The length of mRNA actually consists of a series of three bases (triplets). Each triplet, called a codon, is the code for one amino acid. Once formed, the mRNA separates from the DNA molecule and moves through a nuclear pore and into the cytoplasm, where it begins the process of translation. mRNA strand Ribosome C A T C G TA Translation Waiting in the cytoplasm are tRNA molecules. Each tRNA consists of three bases (a triplet called an anticodon) that will perfectly complement a specific site (the codon) on the mRNA. Attached to the tRNA is the amino acid for that site, according to the genetic “blueprint.” Amino acid The tRNA finds the three bases that are complementary to its own and deposits the amino acid. The ribosome then uses enzymes to attach the lengthening chain of amino acids together with peptide bonds. FIGURE 11.3 Protein synthesis. From Thompson, G. C. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 49. tRNA disengages for reuse When each triplet has been filled with the correct amino acid and the peptide bonds have been formed, the protein is complete. 4068_Ch11_171-201 15/11/14 1:21 PM Page 174 UNIT TWO 174 Understanding Health and Illness of cancer, which is a general term for man y types of malignant growths. Mitosis INTRODUCTION TO CANCER CONCEPTS Mitosis is cell reproduction. One cell, after its 46 chromosomes have replicated, divides into two cells, each with a complete set of chromosomes. Mitosis is necessary for the growth of the body and the replacement of dead or damaged cells. Not all cells are capable of mitosis; of those that are capable, the rate of division varies widely by tissue type. Some cells are capable of only a limited number of divisions; once that limit has been reached and the cells die, they are not replaced. Shortly after birth, almost all neurons lose their ability to divide, and muscle cells ha ve limited mitotic capability. When such cells are lost through injury or disease, the loss of their functions in the individual is usually permanent. Oncology is the branch of medicine dealing with tumors. Oncology nursing is also called cancer nursing; it is an important component of medical-surgical nursing care. The National Cancer Institute (NCI) reports that an estimated 13.7 million Americans alive today have a history of cancer (American Cancer Society [ACS], 2013a). Early accounts of cancer date back to the 17th century B.C. Documentation of the benef its of early cancer detection and treatment exist from the beginning of the 19th century. Today, microscopic technology and genetic engineering provide health care providers (HCPs) with a better understanding of tumor growth and cell activity and a means for early cancer detection and interv ention. Box 11-1 lists some helpful cancer resources. Cell Cycle Benign Tumors The cell cycle involves a series of changes through which a cell progresses, starting from the time it develops until it reproduces itself. The duration of the cell’s life, the time it takes for mitosis to occur, the growth ratio (percentage of cycling cells), the frequency of cell loss, and the doubling time (the time for a tumor—an abnormal mass—to double its size) are important concepts related to tumor gro wth and treatment strategies. At any point in time, some cells are actively dividing, others leave the cycle after a certain point and die, and still others temporarily leave the cycle and remain inactive until reentry into the cycle. Inactive cells continue to synthesize (ribonucleic acid [RNA] and protein; Fig. 11.4). Cells and Tissues A tissue is a group of lik e cells with the same structure and function. The four categories of human tissues are epithelial, connective, muscle, and nervous. Tissues organize into organs; organs construct systems; and systems form the individual. Because of this hierarchy, if a dividing mass of cells is mutated, the abnormality will produce symptoms at the higher levels. Cells that reproduce abnormally result inneoplasms, or tumors. Neoplasm is a term that combines the Greek word neo, meaning “new,” and plasia, meaning “form,” to suggest ne w tissue growth. A benign tumor is a cluster of cells that is not normal to the body but is noncancerous. Benign tumors grow more slowly than malignant ones and have cells that are the same as the original tissue. An organ containing a benign tumor usually continues to function normally. A neoplastic growth is difficult to detect until it contains about 500 cells and is about 1 cm in diameter. Cancer Cancer is a group of cells that grows out of control, taking over the function of the af fected organ. Cancer cells are poorly constructed, loosely formed, and disorganized. A simplistic definition is “confused cell.” An organ with a cancerous tumor eventually ceases to function. Malignant, a term • WORD • BUILDING • oncology: onco—mass + logy—word, reason neoplasm: neo—new + plasm—form Box 11-1 Cell Division (Mitosis) Differentiation Cell growth occurs Organelle Duplication Cell Life Cycle DNA Replication FIGURE 11.4 Cell cycle. Point of Decision to Replicate or Differentiate Resting phase Cancer Resources American Cancer Society 800-4-CANCER (422-6237) www.cancer.org CancerCare 800-813-HOPE (4673) www.cancercare.org www.lungcancer.org National Cancer Institute 301-496-8531 www.nci.nih.gov http://cis.nci.nih.gov Oncology Nursing Society 412-921-7373 www.ons.org 4068_Ch11_171-201 15/11/14 1:21 PM Page 175 Chapter 11 often used to describe cancer , means that the tumor resists treatment and tends to worsen and threaten life. A comparison of benign and malignant tumors is found in Table 11.1. NURSING CARE TIP Teach patients and families that cancer is not contagious. Pathophysiology Cancer is not one disease b ut many diseases with different causes, manifestations, treatments, and prognoses. There are more than 100 types of cancer caused by mutation of cellular genes. Normal cells are limited to about 50 to 60 di visions before they die. Cancer cells do not have a division limit and are considered to be immortal, that is, they keep on dividing, unless they are killed or their host dies. The progression from a normal cell to a malignant cell follows a pattern of mutation, defecti ve division, abnormal growth cycles, and defective cell communication. Cell mutation occurs when a sudden change affects the chromosomes, causing the new cell to differ from its parent. The malignant cell’s enzymes destroy the gluelike substance found between normal cells, which disrupts the transfer of information used for normal cell structure. Cancer cells also lack contact inhibition. Growth-regulating signals in the cells’ surrounding environment are ignored as the abnormal cell growth increases. Cells continue to divide and invade surrounding tissues. Nursing Care of Patients With Cancer 175 Etiology Cancer cell gro wth and reproduction in volve a tw o-step process: initiation and promotion. The first step in cancer growth is called initiation. Initiation causes an alteration in the genetic structure of the cell (DNA). Cell alteration is associated with exposure to a carcinogen, which is a substance or agent that increases the risk of cancer. The cellular change primes the cell to become cancerous. Promotion is the second step of cancer cell growth. It occurs after repeated exposure to carcinogens causes the initiated cells to mutate. During the promotion step, a tumor forms from mutated cell reproduction. A healthy immune system can often destro y cancer cells before they replicate and become a tumor. It is important to remember that any substance that weakens or alters the immune system puts the indi vidual at risk for cell mutation. Medical researchers support the theory that cancer is a symptom of a weakened immune system. Risk Factors Increased risk of cancer is linked to many environmental factors. An evaluation of cancer begins with assessment of wellknown risk f actors such as specif ic viruses; e xposure to radiation, chemicals, and irritants; genetics; diet; hormones; and general immunity. Certain racial and ethnic groups also are at higher risk for some types of cancer (see “Cultural Considerations”). • WORD • BUILDING • carcinogen: karkinos—cancer, crab + genesis—birth TABLE 11.1 COMPARING BENIGN AND MALIGNANT TUMORS Growth rate Benign Typically slow expansion Malignant Often rapid growth; malignant cells infiltrate surrounding tissue Cell features Typical of the tissue of origin Atypical in varying degrees compared with the tissue of origin; altered cell membrane; contain tumor-specific antigens Tissue damage Minor Often causes necrosis and ulceration of tissue Metastasis Not seen; remains localized at site of origin Often spreads to form tumors in other parts of the body Recurrence after treatment Seldom recurs after surgical removal Recurrence can be seen after surgical removal and following radiation and chemotherapy Related terminology Hyperplasia, polyp, benign neoplasia Cancer, malignancy, malignant neoplasia Prognosis Not injurious unless location causes pressure or obstruction to vital organs Death if uncontrolled 4068_Ch11_171-201 15/11/14 1:21 PM Page 176 176 UNIT TWO Understanding Health and Illness Cultural Considerations Many racial and ethnic groups in the United States have high rates of cancer. Although risk factors for the development of specific cancers are similar, barriers to prevention and nursing strategies to reduce risk factors vary among ethnicities. Europeans Foreign-born and first-generation white men from Norway, Sweden, and Germany have an increased risk of stomach cancer. This suggests an interrelation among ethnic, geographic, and dietary risk factors. Assessing for these data among these populations may assist in the diagnostic process. Recent Eastern European immigrants may be at risk for thyroid cancer and leukemia because of the current industrial pollution and radiation exposure from the Chernobyl nuclear disaster in the former Soviet Union in 1986. Some contamination occurred in Estonia, Latvia, Lithuania, and Poland. This may constitute a health hazard and may affect both recent immigrants and visitors to these countries. It is essential for HCPs to carefully screen individuals for these cancers. African Americans Common cancer sites among African Americans include the prostate, breast, lung, colon, rectum, cervix, pancreas, and esophagus. Because African Americans are overrepresented in the working class, they experience increased exposure to hazardous occupations. For example, African American men are at a higher risk for developing cancer related to their work in the steel and tire industries and in factories manufacturing chemicals and pesticides. They have the highest overall cancer rate and highest overall mortality rate, and their 5-year survival rate is 30% lower than that of European Americans. In general, African Americans report later for treatment than European Americans. Colon tumors may be deeper in African Americans, making detection on digital examination more difficult. Poverty, a diet high in fat and low in fiber, and lower levels of thiamine, riboflavin, vitamins A and C, and iron may increase cancer risk among African Americans. Additionally, cigarette smoking, inner-city living with pollution, obesity, and alcohol consumption increase their risk for developing cancer. Lack of access to medical care acts as a barrier to prevention among African Americans. Survival, not prevention, is the priority for some. Additional barriers include a lack of cancer risk teaching and detection in some African American communities, lack of health insurance, and little stigma attached to alcohol consumption and smoking. Strong family ties encourage seeking health care advice from family members before professionals. Primary strategies for preventing cancer and increasing survival among African Americans include using African American professionals as speakers in community activities, using church-based information dissemination, providing forums in African American communities, and addressing smoking advertisements in African American communities. Additional strategies include involving “granny” healers and ministers, changing food preparation practices and amounts rather than changing cultural food habits, involving extended family members in educational campaigns, and using high-profile African American leaders in media campaigns. Hispanics Hispanic populations in the United States have an increased incidence for some types of cancer. Cervical cancer is increased among Central and South American women. Pancreatic, liver, and gallbladder cancer is increased among Mexican Americans. Many Mexican Americans are less aware of the early warning signs of cancer; many are more fearful of getting cancer than the general public; and many work in mining, factories using chemicals, and farming using pesticides. Barriers to preventive health care among many Hispanics include high poverty rates, low educational rates, a preference for HCPs who understand Spanish, a preference for health care information presented in Spanish, a delay in seeking treatments for symptoms, and using lay healers as a first choice in health care. Additionally, many have a fear of surgical intervention because the body will be exposed to air, and many have decreased access to health care. For some, an undocumented immigration status creates a fear of reprisal. Nursing approaches effective among Hispanics include educating lay healers regarding cancer prevention and early warning signs of cancer, using bilingual HCPs, using Hispanic HCPs whenever available, using respected Hispanic community leaders in educational programs, presenting videos in Spanish using Hispanic actors, educating the entire family because of close family networks, and connecting with Hispanic community churches, restaurants, and stores. Additionally, the nurse can use the 1-800-4-CANCER telephone number for Spanish translation and counseling, 4068_Ch11_171-201 15/11/14 1:21 PM Page 177 Chapter 11 Nursing Care of Patients With Cancer 177 Cultural Considerations—cont’d become involved with Hispanic community movements, and provide information in community and regional Hispanic newspapers and community publications. Asians and Pacific Islanders Cervical, liver, lung, stomach, multiple myeloma, esophageal, pancreatic, and nasopharyngeal cancers are higher among Chinese Americans. Chinese-American women have a 20% higher rate of pancreatic cancer. High rates of stomach and liver cancer in Korea predispose recent immigrants to these conditions. Thus, the nurse needs to assess and teach newer immigrants regarding these types of cancer. High rates of stomach, breast, colon, and rectal cancer common among Japanese people may be related to the high sodium content of the Japanese diet, a genetic predisposition, consumption of salted fish and contaminated grain, hepatitis B, cigarette smoking, vitamin A deficiency, low vitamin C intake, and chronic esophagitis. Various barriers to prevention exist: prevention models are not native to their culture; they may lack trust in Western medicine; they have decreased access to health care; some are unable to speak the English language; and for some, an undocumented immigration status creates a fear of reprisal. Nursing approaches to improve cancer risk prevention among Asians and Pacific Islanders include education about prevention versus acute care practice, educating native healers, involvement in the community with respected native leaders, videos and literature in the native language, and incorporating native healing practices such as traditional Chinese medicine. Arab Americans Arab Americans are mainly at risk for lung cancer and other cancers related to smoking. Although many Arab Americans are Islamic and Islamic beliefs discourage tobacco use as well as alcohol or drug use, cigarette smoking continues to be a risk behavior among this population. Arab American women are considered very modest, and rates of breast cancer screening and cervical Pap smears are low. Arab Americans tend to lead a sedentary lifestyle with high fat intake, which places them at higher risk for cardiovascular disease as well as certain cancers. Nursing approaches with this population include promoting awareness and primary prevention strategies. Nurses should encourage cancer screenings and smoking cessation. Because of the modesty of Arab American women, nurses should attempt to ensure that women are given same-sex caregivers to promote breast and cervical cancer screenings. American Indians/Native Americans American Indian populations have an increased risk for skin, pancreatic, gallbladder, liver, and prostate cancer. Risk factors for the development of cancer include obesity, a diet high in fat, high rates of alcohol consumption, and high rates of smoking. Barriers to prevention include a lack of American Indian HCPs, HCPs’ unfamiliarity with American Indian cultures, lack of financial resources, and a lack of integration of American Indian healing practices into prevention practices. Nursing approaches to decrease cancer risk prevention among American Indian populations include the following: incorporate prevention into American Indian healing practices; educate American Indian lay healers regarding cancer prevention practices; work with tribal community leaders; respect modesty, gender roles, and tribal customs; work with the Indian Health Service and Bureau of Indian Affairs; encourage traditional customs of physical fitness and exercise; and encourage dietary portion control and healthy food preparation practices instead of changing cultural food habits. VIRUSES. Certain viruses, such as the oncoviruses (RNA- type viruses), are linked to cancer in humans. A retrovirus is an enzyme produced by RNA tumor viruses and is found in human leukemia cells. The Epstein-Barr virus (EBV), which causes infectious mononucleosis, is associated with Burkitt’ s lymphoma. Herpes simplex virus 2 has been associated with cervical and penile cancers. Human papillomavirus (HPV) is associated with cervical cancer in w omen, penile cancer in men, and cancer of the anus and some head and neck cancers in both sexes. Vaccination against HPV (Gardasil®) is recommended for girls and boys age 11 to 12 (Centers for Disease Control, 2013). Chronic hepatitis B is linked with liver cancer. • WORD • BUILDING • oncovirus: onco—mass + virus 4068_Ch11_171-201 15/11/14 1:21 PM Page 178 178 UNIT TWO Understanding Health and Illness RADIATION. There is an increased incidence of cancer in persons exposed to prolonged or large amounts of radiation. Ionizing radiation involving ultraviolet rays such as sunlight, x-rays, and alpha, beta, and gamma rays plays a major role in promoting leukemia and skin cancers, primarily melanomas. Persons exposed to radioactive materials in lar ge doses, such as a radiation leak or an atomic bomb, are at risk for leukemia and breast, bone, lung, and thyroid cancer . Controlled radiation therapy is used to treat cancer patients by destroying rapidly dividing cancer cells, but radiation can also damage normal cells. The decision to use radiation is made after careful evaluation of the tumor’s location and vulnerability to other treatments. (DES) during pregnancy have an increased incidence of reproductive cancers. DES is a synthetic hormone with estrogen-like properties that was used in the past to prevent miscarriage. Tumors of the breast and uterus are tested for estrogen or progesterone influence. If a breast tumor is malignant, the tumor is tested and treatment v aries depending on whether it is positi ve for estrogen or progesterone dependence. IMMUNE FACTORS. A healthy immune system destroys mu- CHEMICALS. Chemicals are present in air, water, soil, food, drugs, and tobacco smoke. Chemical carcinogens are implicated as triggering mechanisms in malignant tumor development. Length of e xposure time and de gree of e xposure intensity to chemical carcinogens are associated with risk for cancer development. Smoking accounts for 90% of lung cancers in men and 80% in women (National Cancer Institute, 2012). Chemical agents, such as those in tobacco, are more toxic when used with alcohol. Alcohol and tobacco are the most frequent causes of cancers of the mouth and throat. Chemicals used in manufacturing, such as vin yl chloride, are associated with liver cancer. tant cells quickly on formation. An individual with impaired immunity is more susceptible to cancer formation when exposed to small amounts of carcinogens compared with someone with a healthy immune system. Immune system suppression allows malignant cells to develop in large numbers. Altered immunity is noted in persons with chronic illness and stress. An increased risk of cancer follows a traumatic, stressful period in life, such as the loss of a mate or a job. Failure to decrease stress productively contributes to a higher incidence of chronic illnesses. Thus, a cycle of stress, illness, and increased cancer risk de velops. People with acquired immunodeficiency syndrome (AIDS) have a compromised immune system and an increased risk for certain cancers. A decline in the immune system and increase in cancer risk is also noted as the body ages. IRRITANTS. Chronic irritation or inflammation caused by ir- Cancer Classification ritants such as snuff or pipe smoke often cause cancer in local areas. Nevi (moles) that are chronically irritated by clothing, especially clothing contaminated by chemical residue, can become malignant. Asbestos found in temperature and sound insulation has been proven to cause a particularly destructive type of lung cancer. GENETICS. Genetics plays a large part in cancer formation. Certain breast cancers are link ed to a specific gene mutation. Skin, colon, ovarian, and prostate cancers have a genetic tendency. People with Do wn syndrome (a chromosomal abnormality) have a higher risk of de veloping acute leukemia. DIET. Diet is a major factor in both cause and prevention of malignancies. People who eat high-f at, low-fiber diets are more prone to develop colon cancers. Diets high in fiber reduce the risk of colon cancer . High-fat diets are link ed to breast cancer in w omen and prostate cancer in men. Consumption of large amounts of pickled, smok ed, and charbroiled foods has been linked with esophageal and stomach cancers. A diet low in vitamins A, C, and E is associated with cancers of the lungs, esophagus, mouth, larynx, cervix, and breast. HORMONES. Hormonal agents that disturb the body’s bal- ance can also promote cancer. Long-term use of the female hormone estrogen is associated with cancer of the breast, uterus, ovaries, cervix, and vagina. It has been found that children born of mothers who took diethylstilbestrol Cancers are identified by the tissue af fected, speed of cell growth, cell appearance, and location. Neoplasms occurring in the epithelial cells are called carcinomas. Carcinoma is the most common type of cancer and includes cells of the skin, gastrointestinal (GI) system, and lungs (Figs. 11.5 and 11.6). Cancer cells af fecting connective tissue, including fat, the sheath that contains nerv es, cartilage, muscle, and bone, are called sarcomas. Leukemia is the term used to describe the abnormal gro wth of white blood cells (WBCs). Cancers involving cells of the lymphatic system, lymph nodes, and spleen are called lymphomas. See Table 11.2 for cancer types based on origin. LEARNING TIP A person’s cancer risk results from the balance between exposure and susceptibility to carcinogens. Metastasis (Spread of Cancer) Neoplastic cells that remain in one area are considered localized, or in situ, cancers. These tumors may be difficult to visualize on clinical e xamination and are detected • WORD • BUILDING • in situ: in—in + situ—position 4068_Ch11_171-201 15/11/14 1:21 PM Page 179 Chapter 11 FIGURE 11.5 Adenocarcinoma of the cecum. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. Nursing Care of Patients With Cancer 179 through microscopic cell e xamination. In situ tumors are often removed surgically and may require no further treatment. Metastasis is the term used to describe the spread of the tumor from the primary site into separate and distant areas. Metastasis is the stage at which cancer cells acquire invasive behavior characteristics and cause the surrounding tissue to change (Fig. 11.7). Metastasis occurs mainly because cancer cells break a way more easily than normal cells and can survive for a time independently from other cells. There are three steps in the formation of a metastasis. Cancer cells are able to (1) invade blood or lymph vessels, (2) move by mechanical means, and (3) lodge and grow in a new location. Metastatic tumors carry with them the cell characteristics of the original or primary tumor site. As a result, sur geons are able to determine the original tumor site based on metastatic cell characteristics. For example, lung tissue found in the brain suggests a primary lung tumor with metastasis to brain tissue. Common sites of metastasis are the lungs, liver, bones, and brain. Incidence of Cancer FIGURE 11.6 Lung cancer. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. TABLE 11.2 TUMOR DESCRIPTIONS Tumor Type Fibroma Character Benign Origin Connective tissue Lipoma Benign Fat tissue Carcinoma Cancerous Tissue of the skin, glands, and digestive, urinary, and respiratory tract linings Leukemia Cancerous Blood, plasma cells, and bone marrow Lymphoma Cancerous Lymph tissue Melanoma Cancerous Skin cells Sarcoma Cancerous Connective tissue, including bone and muscle Cancer affects all age groups, although the incidence is higher in people aged 60 to 69 years. The second highest age group is ages 70 to 79. Men have a higher incidence of cancer than women. Cancer in people o ver age 60 is thought to occur from a combination of exposure to carcinogens and weakening of the body’s immune system. Some cancers, such as Wilms’s tumor of the kidne y and acute lymphocytic leukemia, are more common in young people. The cause of tumors in young people is not well under stood, but genetic predisposition tends to be a major factor. The most common type of cancer in adults is skin cancer; it is also considered to be the most preventable. Exposure to • WORD • BUILDING • metastasis: meta—beyond + stasis—stand FIGURE 11.7 Invasive metastasis to skin area following mastectomy for breast cancer. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. 4068_Ch11_171-201 15/11/14 1:21 PM Page 180 180 UNIT TWO Understanding Health and Illness ultraviolet radiation (sunlight) increases the risk of skin cancer. Wearing protective clothing and sunscreen can greatly reduce the risk of skin cancer. Lung cancer has the highest of the cancer mortality rates in both men and women and also is commonly preventable. Cigarette smoking is the main cause, along with air pollution and exposure to radon and other chemicals. Men have a high incidence of prostate cancer between ages 60 and 79. Cancer of the colon and rectum has been linked to consumption of high-fat, low-fiber diets and ranks as the third highest cancer in men. The highest incidence of cancer in w omen is in the breast. Women with a family history of breast cancer have a greater risk than those with no family history. Commercial testing for the oncogene linked with breast cancer is available and marketed for high-risk women, especially those in the Ashkenazi Jewish population. Genetic testing is done through genetic counseling programs, and the cost ranges from $700 to $2400, depending on the geographic re gion. See Figure 11.8 for estimated new cancer cases and deaths for 2013. Mortality Rates Cancer survival rates have improved during the past 30 years and, since the 1990s, the number of cancer deaths has decreased for both men and w omen. A 5-year period is used to monitor cancer patients’ progress following diagnosis and treatment. Survival statistics are based on those who live 5 years in remission. Remission is considered to have occurred when all signs and symptoms of cancer ha ve disappeared, even though there may still be cancer in the body. For more information about cancer incidence and mortality data, visit the National Cancer Institute website at www.cancer .gov or the American Cancer Society at www.cancer.org. Early Detection and Prevention Nurses play an important role in pre venting and detecting cancer. You can help educate patients about risk f actors, self-examination, and cancer screening programs. Early diagnosis and treatment provide time to stop the progression of cancer. EARLY DETECTION. Regular physical e xaminations help HCPs detect early w arning signs of cancer. The American Cancer Society recommends mammography (a special x-ray of breast tissue used to detect a mass too small for palpation) is recommended every 1 to 2 years in w omen after age 40 (some sources say after age 50). The U.S. Preventive Services Task Force (2009), however, recommends beginning mammography at age 50 and screening e very 2 years. All women should discuss their individual risk factors and frequency of screening with their physicians. A clinical breast exam is recommended every 3 years for women in their 20s Estimated New Cases* Estimated Deaths Male Female Male Female Prostate 238,590 (28%) Breast 232,340 (29%) Lung and bronchus 87,260 (30%) Lung and bronchus 72,220 (26%) Lung and bronchus 118,080 (14%) Lung and bronchus 110,110 (14%) Prostate 29,720 (10%) Breast 39,620 (14%) Colon and rectum 73,680 (9%) Colon and rectum 69,140 (9%) Colon and rectum 26,300 (9%) Colon and rectum 24,530 (9%) Urinary bladder 54,610 (6%) Uterine corpus 49,560 (6%) Pancreas 19,480 (6%) Pancreas 18,980 (7%) Melanoma of the skin 45,060 (5%) Thyroid 45,310 (6%) Liver and intrahepatic bile duct 14,890 (5%) Ovary 14,030 (5%) Kidney and renal pelvis 40,430 (5%) Non-Hodgkin lymphoma 32,140 (4%) Leukemia 13,660 (4%) Leukemia 10,060 (4%) Non-Hodgkin lymphoma 37,600 (4%) Melanoma of the skin 31,630 (4%) Esophagus 12,220 (4%) Non-Hodgkin lymphoma 8,430 (3%) Oral cavity and pharynx 29,620 (3%) Kidney and renal pelvis 24,270 (3%) Urinary bladder 10,820 (4%) Uterine corpus 8,190 (3%) Leukemia 27,880 (3%) Pancreas 22,480 (3%) Non-Hodgkin lymphoma 10,590 (3%) Liver and intrahepatic bile duct 6,780 (2%) Pancreas 22,740 (3%) Ovary 22,240 (3%) Kidney and renal pelvis 8,780 (3%) Brain and other nervous system 6,150 (2%) All sites 854,790 (100%) All sites 805,500 (100%) All sites 306,920 (100%) *Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder. FIGURE 11.8 Leading new cancer cases and deaths—2013 estimates. From the American Cancer Society, Cancer Facts & Figures 2013. Retrieved June 5, 2013, from www.cancer.org/acs /groups/content/@epidemiologysurveilance/documents/document/acspc-037129.pdf All sites 273,430 (100%) 4068_Ch11_171-201 15/11/14 1:21 PM Page 181 Chapter 11 and 30s and annually after age 40 (ACS, 2013b). However, if a woman has a high risk for breast cancer because of family history, the type and frequenc y of screening should be discussed with her doctor. Initial Papanicolaou testing (Pap smear) for cervical cancer is currently recommended to be gin no later than age 21 and performed every 3 years up to age 29. The preferred approach for women aged 30 to 65 is to have the Pap test with an HPV test, also referred to as cotesting, every 5 years, but it is acceptable to have just the Pap test every 3 years in this age group (ACS, 2013b). After age 65, a woman who has had three normal Pap tests in a row within the past 10 years can choose to stop screening. Some women choose not to be screened, e ven when they have access to health care. Barriers to screening include fear of health care personnel and testing procedures, as well as lack of knowledge. Women who fear cancer but trust their HCPs and seek information are more lik ely to be screened. As a nurse, you can help by developing a trusting relationship and providing information to your female patients. The ACS considers monthly breast self-e xaminations to be optional for women and testicular self-examinations to be optional for men. ACS guidelines encourage everyone to be familiar with their bodies and to report changes to their HCPs. Offer men and women instruction in breast and testicular self-examinations if they are interested in doing them. The ACS (2013b) recommends one of the follo wing options to screen for colorectal cancer, beginning at age 50: Tests that find polyps and cancer • Flexible sigmoidoscopy every 5 years • Colonoscopy every 10 years • Double-contrast barium enema every 5 years • Colonography (virtual colonoscopy using computed tomography) every 5 years. Tests that mainly find cancer • Fecal occult blood test every year • Fecal immunochemical test every year If any tests are positive, a colonoscopy should be done. Before 2009, the ACS recommended annual digital rectal examination and prostate-specific antigen (PSA) blood testing for men aged older than 50 years with a life e xpectancy of at least 10 years and for younger men at higher risk. More recently, ACS withdrew this recommendation because routine screening has not been shown to prolong lives (ACS, 2013b). It seems reasonable, however, to still offer these tests as options to men in these populations. GENETIC TESTING. Currently, much attention is directed toward genetic testing and identif ication of persons at risk for cancer. Genetic testing technology poses both legal and ethical questions concerning confidentiality and insurance cost issues. The cooperation of family members is important because genetic testing is done after a family member has been diagnosed with cancer. Family members may e xperience a variety of emotions surrounding the increased risk for themselv es and Nursing Care of Patients With Cancer 181 their guilt over the role the y may have played in increasing the risk for their children. HEALTHY LIFESTYLE. Promotion of healthy lifestyles, including proper diet and e xercise, helps strengthen the immune system and reduce cancer risk. Smoking is the most preventable cause of death from lung cancer, and smoking cessation is the subject of ongoing campaigns by theAmerican Cancer Society. Secondhand smoke contributes to a signif icant increased risk of lung cancer in nonsmokers as well. PROTECTANT FOODS. Much research related to diet and cancer risk is being conducted. A diet poor in folate, a B vitamin, can lead to development of cancers of the colon, rectum, and breast. Folate is best obtained by eating fruits, vegetables, and enriched grain products. People who ingest a diet high in saturated f at are at a greater risk of obesity, which can be a risk f actor for colon, prostate, and breast cancers. A diet rich in vegetables and fruits can reduce the risk of lung, oral, esophageal, stomach, and colon cancer. The ACS recommends eating a variety of fresh fruits and v egetables daily. Because it is not kno wn which compounds in vegetables and fruits are actually benef icial, there are no supplements that can take the place of eating whole foods. Frozen and canned foods can be healthy alternatives, but be careful to read labels for ingredients. See www.cancer.org and “Nutrition Notes—Reducing Cancer Risk” for additional dietary recommendations. Nutrition Notes Reducing Cancer Risk Throughout life, excessive energy (calorie) intake and obesity increase cancer risk. Proportions of meals should be: • 2/3 (or more) vegetables, fruits, whole grains, and legumes • 1/3 (or less) animal protein Selections should be varied and include: • Vitamin C rich fruits (e.g., oranges, cantaloupe, strawberries) • Cruciferous vegetables (e.g., cabbage, broccoli, Brussels sprouts, cauliflower) • Low-fat dairy products Consumption of the following should be limited: • Excessive red meat, especially when • processed (smoked, salted) • charbroiled or cooked at high temperatures • Excessive fat, especially saturated fat • Highly processed carbohydrates • Recommended alcohol intake, if any, should be limited to one (women) or two (men) standard drinks per day (12 oz. of beer, 5 oz. of wine, or 1.5 oz. distilled spirits) 4068_Ch11_171-201 15/11/14 1:21 PM Page 182 182 UNIT TWO Understanding Health and Illness VACCINES. Preventive vaccines are being developed for cancers associated with specific viruses. Gardasil (a vaccine for HPV) can be given to prevent a variety of cancers, as mentioned earlier. Most cancer vaccines are therapeutic rather than prophylactic and are used to stimulate the patient’s immune system to destroy cancer cells. Currently, the only therapeutic cancer vaccine approved by the Food and Drug Administration is sipuleucel-T for the treatment of adv anced prostate cancer that no longer responds to hormone therapy (ACS, 2013c). Vaccine therapy for malignant melanoma and lymphoma is being tested. Diagnosis of Cancer A cancer diagnosis is a frightening e xperience (see “Patient Perspective”). Often, people try to mask symptoms because they are so frightened of the disease.A physical examination along with careful and thorough assessment of the patient’ s current status, medical and sur gical histories, and pertinent family history should be completed. The most conclusive information about the health of tissue is acquired by examining cell activity through biopsy. For explanations of the following tests, see Appendix A. Patient Perspective I am a 43-year-old woman with three children and in the prime of my life—at least that’s what I thought. That was before I was diagnosed with cancer in my left breast. I was breastfeeding at the time I felt the lump and, although I went for a biopsy, I felt sure the lump resulted from a blocked milk duct or fibroid cyst. But, unbelievably, the biopsy came back positive for cancer. My whole life flipped upside down. I was devastated. I was scheduled for surgery within a week, and my emotions were in complete turmoil. I felt nauseated all the time, vomited almost every morning, and had diarrhea daily. My stomach felt like it had a pot of bees inside. I never cried so much in my life. Thinking about all the tests, the surgery, and the untold ways my life could be affected made me a nervous wreck. Finally, I got down on my knees and turned this whole crisis over to God. I couldn’t handle it anymore, so I asked God to give me peace, and I placed all my trust and faith in Him. It worked, and I was finally able to get control and face this thing head-on. As I went for further testing, everyone made me feel like I was the at the center of the care system because wherever I went, whatever tests I had done, there were always compassionate nurses and technicians who either directed me to others who had suffered from breast cancer in their facility or were going through the treatments and told me to come and talk to them if I ever needed help or support or just had any questions. Some actually broke down with me because they had endured this same disease. We would hold each other and then exchange phone numbers just to talk if I needed it. It was very encouraging to know these women had made it through, and I could too. The surgery went smoothly, and I was released the next day. There wasn’t much discomfort, and I felt good physically. The nerve was removed, and a scar runs from the center of my chest down under my armpit. I was able to return to work in 3 weeks. The doctor gave me a prescription for a prosthesis as soon as the drains were removed and I began healing. We went to a specialty place to be fitted, and, although the prosthesis was nothing like the real thing, I looked normal, and it helped to build my confidence. The impact on my family was one of complete bewilderment because I had no family history of this type of cancer. Everyone tried to help with positive sentiments like “we caught it early,” “breast cancer has a high cure rate,” “periodic follow-up can keep you cancer free,” and so on. My husband and children supported and comforted me. I tried to focus on them because I want to be there for them when they graduate, get married, etc. My mother and sister helped get me to all my appointments and filled my prescriptions. Chemo was advised as a follow-up treatment, and I was scheduled for four rounds, one every 3 weeks. This was undoubtedly the worst thing I have ever endured. Not even giving birth can compare to the way chemo makes you feel. I had a very bad experience the first round and was extremely sick and unable to eat for 5 days. I wondered why I didn’t just die from the cancer because I felt that this was killing me. Before the second round, I told the doctor how violently ill I’d been, and she adjusted the dosages of some of the drugs. I was very groggy; although I didn’t vomit, I still wasn’t feeling myself. For the third round, they changed a medication and I withstood the side effects a lot better—although I was still nauseated, lightheaded, fatigued, and unable to focus, eat, or taste anything. At times, it was hard just to put one foot in front of the other. They prepared me for the loss of my hair, but you really don’t know how hard that is until it starts coming out in globs. Not just the loss, but then you have such a long time to wait for it to grow back. When the chemo is over, it’s hard to look back and feel the way you did then, but when you look in the mirror and your hair is still gone, it’s a hard reminder. All through being diagnosed and dealing with breast cancer I have felt a tremendous outpouring of love and caring, not only from my immediate family but also from my church family. I was never so well taken care of. All the hugs, cards, calls, food, and flowers brought to the house encouraged me tremendously. It makes it a little easier to cope when you know you have 4068_Ch11_171-201 15/11/14 1:21 PM Page 183 Chapter 11 so many people who care and are concerned enough to take time out of their daily lives to give you support. I’m lucky because my sister is an RN and prepared me for many of the side effects and difficulties. She was also there to help ask questions and get information from other survivors that kept me in a positive frame of mind. I know that without her help and God’s grace and peace, my recovery would not have been so easy. Looking back I can’t really feel all those terrible emotions and symptoms, but I still am afraid of the unknown. It is not easy when it is you and not someone else this happens to. Now that I’m through the worst part of this, I take positive steps every day to enjoy the little things in life. I feel that the more you keep involved in everyday activities and become educated about the disease and its treatments, the easier it is to deal with. I am taking a drug called tamoxifen now and will be for 5 years. Two of the side effects are hot flashes and sweats. If this is all I have to deal with, however, praise God. My prognosis is very good, and I am expecting a complete cure because I am a survivor. Nursing Care of Patients With Cancer 183 FIGURE 11.10 Stereotactic biopsy of a brain lesion. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. BIOPSY. Accurate identification of a cancer can be made only by biopsy. Microscopic examination of a sample of suspected tissue or aspirated body fluid can confirm the presence of mutant cells. A biopsy is commonly done in an HCP’s office or outpatient surgery department. See Figures 11.9 and 11.10 for two types of biopsy. RADIOLOGICAL PROCEDURES. X-ray examination is a valu- able diagnostic tool in detecting cancer of the bones and hollow organs. Chest x-ray examination is one diagnostic test used in detecting lung cancer. Mammography is a reliable and noninvasive low-radiation x-ray procedure for detecting breast masses (Fig. 11.11). FIGURE 11.11 Mammogram. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. Contrast media x-ray studies are used to detect abnormalities of bone and the GI and urinary systems. Contrast media can be gi ven by various methods. Barium is gi ven orally for visualization of the esophagus and stomach or rectally as a barium enema for visualization of the colon. IV injection of contrast media is used for lung and brain scans. Computed tomography (CT) scans are important in the diagnosis and staging of malignancies and can detect minor variations in tissue thickness. The use of a contrast medium enhances the accuracy of an abdominal CT scan. CT scans are also used to improve the accuracy of inserting a fine needle for biopsy. NUCLEAR IMAGING PROCEDURES. Nuclear medicine imagFIGURE 11.9 Fine-needle breast biopsy. Photo courtesy of Dinesh Patel, MD, Medical Oncology, Internal Medicine, Zanesville, OH. ing involves camera imaging of organs or tissues containing radioactive media. Radioactive compounds are given intravenously or by mouth. These studies are highly sensitive and 4068_Ch11_171-201 15/11/14 1:21 PM Page 184 184 UNIT TWO Understanding Health and Illness can detect sites of abnormal cell gro wth months before changes are seen on an x-ray. Positron emission tomography (PET) scanning provides information about cellular function. Patients are given biochemical compounds, and images are made of the tissue through gamma-camera tomography. PET scans have been useful in brain imaging as well as the detection of the spread of cancers of the lung, ovaries, colon, rectum, and breast. ULTRASOUND PROCEDURES. Ultrasonography helps detect tumors of the pelvis and breast. Ultrasound also may be used to distinguish between benign and malignant breast tumors. MAGNETIC RESONANCE IMAGING. Magnetic resonance imaging (MRI) is valuable in the detection, localization, and staging of malignant tumors in the central nerv ous system, spine, head, and musculoskeletal system. TABLE 11.3 TUMOR MARKERS AND ASSOCIATED CANCERS Tumor Marker Alpha-fetoprotein (AFP) Associated Cancer Hepatocellular cancer Cancer antigen (CA) 15-3 Breast cancer (useful in monitoring patient response to therapy for metastatic breast cancer) CA 125 Ovarian, cervical, liver, and pancreatic cancers CA 19-9 Colorectal, pancreatic, and hepatobiliary cancers (used to aid diagnosis and evaluation) Carcinoembryonic antigen (CEA) Colon and rectal cancers Prostatic acid phosphatase (PAP) Prostate cancer Prostate-specific antigen (PSA) Prostate cancer ENDOSCOPIC PROCEDURES. An endoscopic examination al- lows the direct visualization of a body ca vity or opening. Endoscopy enables the surgeon to biopsy tissue and is used to detect lesions of the throat, esophagus, stomach, colon, and lungs. LABORATORY TESTS. For normal values for the following lab- oratory tests, see Appendix B. Blood, serum, and urine tests are important in establishing baseline v alues and general health status. An elevated white blood cell (WBC) count is expected if the patient has e vidence of infection; ho wever, an increase in WBCs without infection raises suspicion of leukemia. Fifty percent of patients with li ver cancer have increased levels of bilirubin, alkaline phosphatase, and glutamic-oxaloacetic transaminase. Bone marrow aspiration is done to learn the number , size, and shape of RBCs, WBCs, and platelets. Bone marrow aspiration is a major tool for diagnosis of leuk emia. (See Chapter 27 for a description of this test and related nursing care.) Tumor markers, also called biochemical markers, are proteins, antigens, genes, hormones, and enzymes produced and secreted by tumor cells. Tumor markers help confirm a diagnosis of cancer, detect cancer origin, monitor the effect of cancer therapy, and determine cancer remission. Some examples of tumor markers are shown in Table 11.3. CYTOLOGICAL STUDY. Cytology is the study of the formation, structure, and function of cells. Cytological diagnosis of cancer is obtained mainly through P ap smears of cells shed from a mucous membrane (e.g., cervical, anal, or oral). Test results are based on the de gree of cell abnormality . Slight cellular changes are considered normal, with a possible link to abnormal cells seen in infection. Signif icant cellular changes reflect a higher probability of precancerous or cancerous activity. Staging and Grading Tumor staging is used to determine the stage of solid tumor masses, providing valuable information to guide treatment plans. The most common system used for staging is the tumor-node-metastasis (TNM) system, an international system that allows comparison of statistics among cancer centers. This staging system classifies solid tumors by size and degree of spread (Table 11.4). For example, a breast cancer staged as T3 N2 MX is a large breast cancer that has spread to regional lymph nodes, but metastasis cannot be evaluated at this time. The TNM ratings correspond with one of five stages, but stages may differ based on the type of cancer. In general, the lower the number of the stage, the less the cancer has spread. A higher number means a more serious situation e xists. In this classification system, stages range from stage 0 (tumor in situ, no in vasion of other tissues) to stage IV (distant metastasis to other sites). A rating system has also been established to define the cell types of tumors. Tumors are classified according to the percentage of cells that are differentiated (mature). If the tissue of a neoplastic tumor closely resembles normal tissue, it is called well differentiated. A poorly differentiated tumor is a malignant neoplasm that contains some normal cells, b ut most of the cells are abnormal. The better defined or differentiated the tumor, the easier it is to treat. Treatment for Cancer There are three main types of treatment for cancer: surgery, radiation therapy, and chemotherap y. To find out more about cancer treatment options, visit the ACS website at www.cancer.org. 4068_Ch11_171-201 15/11/14 1:21 PM Page 185 Chapter 11 TABLE 11.4 TUMOR-NODE-METASTASIS SYSTEM FOR CANCER STAGING Primary Tumor (T) TX Primary tumor cannot be evaluated T0 No evidence of primary tumor Tis Carcinoma in situ (early cancer that has not spread to neighboring tissue) T1, T2, T3, T4 Size and/or extent of the primary tumor Regional Lymph Nodes (N) Regional lymph nodes cannot be NX evaluated N0 No regional lymph node involvement N1, N2, N3 Involvement of regional lymph nodes (number and location of lymph nodes) Distant Metastasis (M) Distant metastasis cannot be MX evaluated M0 No distant metastasis M1 Distant metastasis Note: From the U.S. National Institutes of Health. Updated 2013. Cancer staging. Retrieved July 6, 2013, from www.cancer.gov/cancertopics /factsheet/detection/staging SURGERY. Surgery can be curative when it is possible to remove the entire tumor. Skin cancers and well-defined tumors without metastasis can be removed without any additional intervention. For some tumors, as much of the tumor is removed as possible (this is called deb ulking), and follow-up chemotherapy or radiation is used to treat the remaining tumor cells. Prophylactic surgery is used to remo ve moles or lesions that have the potential to become malignant. Colon polyps are often removed to prevent malignancies from developing, especially if the polyps are considered premalignant. An extreme example of prophylactic surgery is a woman who elects to have a mastectomy (surgical removal of the breast) because of a high incidence of breast cancer in her family. Surgery also may be done for palliation (symptom control). Surgical removal of tissue to reduce the size of the tumor mass is helpful, especially if the tumor is compressing nerves or blocking the passage of body fluids. The goals of palliative surgery are to increase comfort and quality of life. Reconstructive surgery can be done for cosmetic enhancement or for return of function of a body part. F acial reconstruction is important for a patient’ s self-image after Nursing Care of Patients With Cancer 185 removal of head or neck tumors. Women can elect to have breast reconstruction after mastectomy. Nurses should encourage patients to e xpress and discuss their fears. Patients with a limited understanding of cancer may fear that tissues will not heal postoperati vely. Provide information about wound care, including dressing changes and drainage tubes, to increase the patient’s knowledge base and sense of control. Visual aids concerning tumor site and surgical procedures are valuable teaching tools. Patients who are undernourished are poor surgical candidates and require interv ention such as enteral or parenteral nutrition before and after sur gery. Patients with cancer also are at increased risk for postoperative deep venous thrombosis (DVT). Preoperative teaching includes the importance of leg movement, early ambulation, wearing antiembolism stockings, and recognizing symptoms of D VT, such as calf redness, warmth, or pain. RADIATION. Radiation is used commonly in cancer control and palliation, and it can be curati ve if the disease is localized. The decisi