Medical 7-Cancer Lecture-Cancer Care

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What is cancer?: a large group of diseases (over 200) characterized by uncontrolled growth and spread of abnormal cells
Basic facts about cancer?: universal disease...
affects people without regard
to race, gender, socio-
economic status or
culture...
leading cause of death of all
deaths in the U.S. in 2002
it is estimated...
1,359,150 new cancer cases
will be diagnosed, not
including basal and
sqaumous cell skin cancers
of which there will be
over 800,000 cases...
cancer is a disease of
genetics - a disease of the
cell
What is epidemiology?: FOCUSES ON:
study of disease in popula-
tions; originally focused
on infectious disease...
on relationships...
individuals' characteristics,
their exposures, behaviors
changing focus from acute to
chronic illnesses

GOAL:
to determine the origins of
disease in order to
prevent, reduce its impact
What does cancer surveillance require?: a systematic collection of
data which monitors in
disease frequency and
changes in prevalence of
risk factors
National Cancer Act 1971 says?: mandated collection, analysis
and dissemination of
data--surveillance,
epidemiology, end results,
(SEER) database
SEER data updated annually,
based on 11 population
registries and 3 supple-
mental registries (14%
population)
Cancer Survival Rates What is the overall survival of Caucasians from cancer?: 63% in 1997 contrasted with 33% in 1960
What is the cancer survival rate for AA?: 52%...AA has the highest incidence of death or mortality from cancer...more Caucasians get cancer, but more AA's die from it...due to absence of care and sociological phenomena associated with it
How many cancer survivors are in the U.S.: eight million
Which cancers have a high rate of survival?: breast
Hodgkins
leukemia
melanoma
prostate
thyroid cancers
uterine
There's been little improvement in survival for which 3 cancers?: cervix
larynx
oral cancers
The estimated 2006 most deadly cancer in men and women is?: lung and bronchus
The cancer with the highest incidence rate in women in 2006 is?: breast cancer
The cancer with the highest incidence rate in men in 2006 is?: prostate
2006 estimated cancer INCIDENCE rates for men?: prostate
lung and bronchus

Cancers 10% rate and lower?
colon and rectum
urinary bladder
melanoma of skin
non-Hodgkin lymphoma
kidney
oral cavity
leukemia
pancreas
all other sites 18%
2006 estimated cancer INCIDENCE rates for women?: breast
lung and bronchus
colon rectum

Cancers 6% rate and lower?
uterine corpus
non-Hodgkin lymphoma
melanoma of skin
thyroid
ovary
urinary bladder
pancreas
all other sites 22%
2006 death rate for men?: lung and bronchus

Cancers 10% and lower?
colon and rectum
prostate
pancreas
leukemia
liver and intrahepatic
bile duct
esophagus
Non-Hodgkin lymphoma
urinary bladder
kidney
all other sites 23%
2006 death rate for women?: lung and bronchus
breast

Rate falls to 10% and below:
colon and rectum
pancreas
ovary
leukemia
non-Hodgkin lymphoma
uterine corpus
multiple myeloma
brain/ONS
all other sites 23%
Almost half of children's cancers are related to _________?: hematological...blood and lymph related
ex: leukemia
lymphoma
What is a risk factor?: puts person at higher probability of coming down with something
What is host modification?: changing cellular environment and making it more hospitable to normal cells
What is regulation?: looking at screening guidelines...things that are in place for primary and secondary prevention
How can oncology nurses intervene regarding risk status?: education
host modification
regulation
What are some of the etiologies of cancer?: exact cause for some cancers
are still unknown...
immune
autoimmune
genetic
oncogenes
viral (not communicable)
The predisposing factors for cancer are?: drugs/chemicals
exposure to sun
genetics/familial
high dose radiation
irritation of body parts
low resistance to infection
nutritional factors
smoking
Unchangeable risks?: hereditary
past exposures
aging process
How does the aging process promote cancer growth?: longer duration of carcino-
genic exposure
increased susceptibility of
cells to carcinogens
decreased ability to repair
DNA
oncogenic activation or tumor
suppression gene loss
decreased immune surveillance
When identifying risks for cancer, assess the following?: access to care
+education
+cultural beliefs
+perception of risk
+recognition of symptoms
delays in diagnosis and
treatment
family history
family pedigree
lifestyle
social history
socioeconomic status (SES)
work history
Cancer INCIDENCE of poverty are? (6): cervical
esophageal
lung
oral
pancreas
stomach
Cancer INCIDENCE of affluent are? (7): breast
colon
endometrium
prostate
rectum
skin
testis
SES (socioeconomic status) has an inverse relationship with _______ for all cancers?: mortality
Exogenous influences of socioeconomic status on patterns of cancer onset progression are?: health behaviors
life-style
medical care
acceptability
accessibility
availability
Endogenous influence of socioeconomic status on patterns of cancer onset progression are?: co-morbidities
coping
endocrine
immune
nutritional status
resiliency
social support
stress
As much as _____% of all human cancer is related to lifestyle or environmental factors.: 80%
What are primary prevention measures which equate to lifestyle changes? (5): avoiding tobacco use
exercise
high fiber, low fat diet
protection from sun
safe sex
What are 9 ways to reduce cancer risk with a healthy lifestyle?: avoid overexposure in the
sun...
eat a healthy diet...
get plenty of exercise...
don't smoke or use tobacco
in any form...
have a physical exam on a
routine basis, incl. a
mammogram, PAP smear,
testicular, and colon exam
get plenty of sleep (6-8 hrs
per night)
keep weight within normal
limits
practice self-exams faith-
fully
know and follow health and
safety rules at the
workplace
ex: HazMat
Socioeconomic status is a major determinant of what?: cancer survival
90% of cervical cancers are related to?: human papilloma virus (HPV)
To reduce cancer risk, limit fat intake to _____ to _____ percent total calories?: 20 to 30%
To reduce cancer risk, is it better to increase or decrease fiber?: increase
To reduce cancer risk, how much alcohol is allowed?: limit alcohol to less than two drinks per day
To reduce cancer risk, eat foods high in vitamins ___ & ____ which are found in which foods?: A & C

leafy green vegetables
yellow vegetables
fresh fruits
To reduce cancer risk, eat more cruciferous vegetables (named for cross-shaped blossoms) such as?: broccoli
brussel sprouts
cabbage
rutabagas
sprouts
turnips
What is found in meats that should be reduced in consumption to reduce the risk of cancer?: nitrates (a preservative
found in some processed
meats)
To reduce cancer risk, reduce intake of red?: meat
Explain 3 generation pedigree?: 1st generation is the patient and their siblings...
2nd generation is the parents...
3rd generation is the grandparents
What is a pedigree (family tree)?: a graph of a family history for a specific trait or health problem over several generations
A healthy diet to reduce cancer risks is vegetarian and includes a diet ____ in fiber, _____ in fat, and a _______ amount of protein: high
low
moderate
To reduce risk of cancer, add dark green and yellow vegetables, cruciferous vegetables, beans, folate, and orange juice.: okay
To reduce cancer risk, add the following vitamin and minerals with antioxidants in them (3)?: vitamin C
beta carotene
selenium
To reduce cancer risk, add the following phytochemicals (3)?: isoflavones
lycopene
polyphenols
To reduce cancer risk, drink green and black tea and lower alcohol.: okay
The single most preventable cause of illness and premature death in the U.S. is?: tobacco use
The average life expectancy for a chronic smoker is about ____ years shorter than for a nonsmoker?: 15
Smokeless tobacco can also lead to nicotine addiction and dependence, and increased risk for what 3 types of cancer?: esophageal
larynx
throat
Define primary prevention?: use of strategies to prevent actual occurrence of cancer...this method of cancer prevention is most effective when there is a known cause for a cancer type
Define secondary prevention?: use of screening strategies to detect cancer early, at a time when cure or control is more likely
What is the difference between UVA and UVB radiation?: ?
Three types of skin cancer are?: basal cell carcinoma
malignant melanoma
squamous cell carcinoma
To avoid excessive sun exposure, apply SPF 15 _____ minutes prior to sun exposure?: 30
Potential occupational hazarads that might cause cancer include?: asbestos fibers
bischlormethyl ether
chromium compounds
nickel and uranium dusts
vinyl chloride
Breast self-exam for 40+ years?: annual mammogram
annual clinical breast exam
monthly breast self exams
Breast self-exam 20-39 years?: clinical breast exam every 3
years
monthly breast self exams
What are the screening guidelines for ovarian cancer?: none
What is the tumor marker for ovarian cancer?: CA-125
Diagnostic study for ovarian cancer?: transvaginal ultrasound
Ovarian cancer vague signs and symptoms?: abdominal fullness
bloating
pelvic pressure
fatigue
What is a colonoscopy?: a procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer...a colonoscope (a thin, lighted tube) is inserted through the rectum into the colon...polyps or tissue samples may be taken for biopsy
What is a digital rectl exam?: DRE...an exam of the rectum...the doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual
Diagnostic studies for lung cancer?: CXR
spiral CT
no screening guidelines
Acronym for warning signals of cancer?

CAUTION ***(a special handout was given for this): Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion or difficult swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Late signs and symptoms?: anemia
anorexia
fever
weakness
weight loss
Nurse's role in assisting with diagnostic procedures?: give support
lengthy process
tiring process
frightening process
requires client education,
preparation, cooperation
History and physical exam?: allergies
concurrent disorders
family medical history
general information
(demographic data)
general review of systems
present state of health and
life style
presenting complaint
previous state of health
Laboratory tests?: UA-urine analysis,
nonspecific
Stool-guaiac-tests for occult
blood in stool-indicator
of GI cancer
serum chemistries
electrolytes-NA+, K+, Cl-,
CO2-
glucose
BUN (blood urea nitrogen) and
Cr (creatinine)-monitors
renal function
CBC
RBC
Hgb & Hct
WBC
Pits
What is a guaiac stool lab test?: tests for occult blood in stool...an indicator of GI cancer
What is a creatinine test?: monitors renal function
How is the RBC lab test affected by cancer?: often decreased in lymphoma and leukemia, monitored during chemotherapy/radiation
What does the Pits lab test monitor?: thrombocytes
What does the specialized cancer lab test tumor marker monitor for?: monitors for specific proteins, antigens, genes, hormones or enzymes...released by cancers
What does the specialized lab test acid phosphatase monitor for?: prostate
What does the specialized lab test alkaline phosphatase monitor for?: bones
liver
What does the specialized lab test Bence Jones Protein monitor for?: immunoglobins found in urine of patients with multiple myeloma, associated with tumor metstasis to bone, lymphatic tissue
What does the CA-15-3 specialized cancer lab test monitor for?: cancer antigen, tumor marker for monitoring breast cancer
What is the CA-19-9 cancer tumor marker for?: cancer antigen...pancreatic carcinoma
What is the CA-125 tumor marker for?: cancer antigen...ovarian cancer
What is CEA?: carcionembryonic antigen...tumor marker...colorectal, breast, lung, often the first indication of recurrence
What is AFP?: alpha
fetoprotein
testicular, liver
What is PSA?: prostate specific antigen...
more sensitive than acid
phosphatase
What is HCG?: human chorionic gonadotropin-
choriocarcinoma
What is serum calcitonin?: thyroid
lung
breast
pancreas
Radiological studies include (7)?: CT scanning
mammogram
MRI
PET
scans - radioisotope
ultrasound
x-rays
How are x-ray studies used to diagnose cancer and which cancers are first detected on x-ray?: to visualize internal structures...lung and GI cancers are first detected on x-ray
How is CT scanning used to diagnose cancer?: CT scanning is computerized axial tomography - 3 dimensional cross section, useful for chest, abdominal cavity and brain
What does PET stand for?: positron emission tomography
What is MRI used for?: magnetic resonance imaging...
sectional images using magnetic firlds, useful for detecting tumors of bone and CNS
What are scans - radioisotope used for?: rely on radioactive substances, useful in liver, spleen, lungs, heart, thyroid, brain, urinary tract
What is ultrasound used for?: high frequency ultrasound waves, useful in assessing pelvis, heart, abdomen
What are two types of invasive diagnostic techniques?: ENDOSCOPY...permits "direct" visualization of internal structures....
requires informed consent, check allergies...
biopsy is often done during
an endoscopic procedure

CYTOLOGY...study of cells and fluids obtained by brushings, scrapings, smears or needle aspiration - direct examination of cells -leads to a definitive diagnosis
What is an endoscopy?: permits "direct" visualization of internal structures....
requires informed consent, check allergies...
biopsy is often done during
an endoscopic procedure
What is cytology?: study of cells and fluids obtained by brushings, scrapings, smears or needle aspiration - direct examination of cells -leads to a DEFINITIVE diagnosis
What is a biopsy?: removal of sample tissue for microscope exam, leads to a?

requires informed consent
check allergies
Histology of tissue (10)?: aspiration
bone marrow
endometrial
excisional
frozen section
incisional
liver
lung
pleura
Cytology of cells (8)?: bronchoscopy
endoscopy
gastric analysis
lumbar puncture
peritoneoscopy
PAP smear
sputum
When taking a cancer family history, obtain at least how many generations of pedigree?: three
Ask about ALL individuals in the family and record...questions to ask are?: age at cancer diagnosis...
age at and cause of death...
bilateral vs unilateral
cancer...
primary vs metastatic
cancer..
precursor lesions?
ex: LCIS
DCIS
record ethnicity and race
What does pedigree help to decide with?: risks to patient and family members...
obtaining medical records to
confirm diagnosis...
consultation with expert in
cancer genetics
referrals for screening,
prevention, and support
offering genetic testing
Common pedigree symbols (10)?: adopted
affected with trait
deceased
dizygotic twins
male, female
mating
monozygotic twins
mutation carrier
proband (patient initiating
genetic workup)
sibship
Information to obtain about AFFECTED relatives?: current age
age at and date of diagnosis/
death
type and location of primary
cancers(s), stage and
laterality
second cancer: metastasis or
new primary?
environmental exposures (ie,
smoking, sun)
ethnicity/race
Information to obtain about unaffected relatives?: current age
health status and history
of significant illnesses
presence of other physical
findings associated with
cancer syndromes
if deceased, cause of and
age at death
When to suspect hereditary cancer syndrome: cancer in 2 or more close
relatives (on same side of
family
early age at diagnosis...
multiple primary tumors...
bilateral or multiple rare
cancers
constellation of tumors
consistent with specific
cancer syndrome (ie,
breast and ovary)
evidence of autosomal
dominant transmission
Cancer risk assessment: Key points?: assess patient's perception
of cancer risk...
obtain a careful family
history that includes at
least three generations...
keep cancer family histories
up to date...
confirm verbal reports with
pathology records...
know the benefits and
limitations of quantitive methods to estimate cancer risk...
Genetic predisposition testing is a multi-step process?: identify at-risk patients
provide pretest counseling
and psychological assess-
ment
provide informed consent
select and offer test
disclose results
provide post-test counseling and follow-up
When should genetic testing be considered?: patient has a reasonable
liklehood of carrying an
altered cancer susceptibility gene....
genetic test is available
that can be adequately interpreted...
results will influence medical management
patient wans information (empowerment)
Interpreting a positive result..result is a disease-associated mutation?: cancer risk...true positive...cancer risk depends on penetrance
Interpreting a positive result...result is a variant of uncertain significance: cancer risk...inconclusive result...cancer risk not yet known
Interpreting a positive result...neutral polymorphism: no effect on cancer risk
A multi-step process: post-test genetic counseling: assess patient response to results disclosure...
review meaning of result...
discuss patient's plans for
sharing results with family...
discuss medical follow-up plan...
Importance of longitudinal follow-up?: review management plan
periodically...
assess and promote adherence to plan
coordinate primary care and
specialty services
provide psychological support...
keep current on new information and tools for managing inherited cancer
susceptibility...
update family history
Implications for patient care as a direct caregiver, the generalist oncology nurse?: has knowledge of genetic principles
identifiees significant risk factors
performs a basic cancer risk
assessment
three generation of
pedigree
consults as needed with
genetics experts
ensures informed consent for
genetic testing and
therapeutics
provides psychological
support to client/family
going through genetic
testing or decision making
activities
Implications of patient care as an educator?: assesses client/family's learning/psychological needs re-genetic services
answers basic questions and addresses basic concerns
Implications for health policy?: decision making regarding the use of genetic technology..
standards set by national
professional groups
recognition of
professional nurse as
provider of genetic
services...
economic infuences on
decision making based on
genetic information and
testing...
ethical implications
Ethical, social, economic issues?: fair use of genetic interventions...
equal access to genetic health care...
potential for..
need for...
potential for fragmented care of individuals and families with genetic conditions...
"genetic discrimination" in health insurance is illegal?: Health insurance Portability and Accountability Act (HIPAA)
prohibits group health
insurance plans from
discriminating on the
basis of genetic
information

most states have enacted additional protection

family members do not have to disclose whether a relative has undergone genetic testing
Cancer as a genetic disease?: all cancers are genetic and involve changes in genetic material of the somatic cells, sporadic, acquired mutation "2nd hit theory"
Cancer as an inherited disease?: only a small proportion of cancers are inherited; or passed from one generation to the next through germine mutations (approximately 5-10%)
Define gene?: a segment of DNA that contains genetic information necessary to control a certain function, such as the synthesis of a polypeptide (structural gene), this segment is often referred to as a site, "locus", on a chromosome
Define alleles?: one of the variant forms of a particular locus, or location on a chromosome...different alleles produce variations in inherited characteristics and may be recessive or dominant
Define penetrance?: the degree to which the proporation of individuals with a given genotype express the expected phenotype

the gene is present and either is or is not expressed (all or none)

in many of mutations associated with hereditary cancer, penetrance is incomplete

some mutations have higher risk of cancer than others
Penetrance can be contrasted with?: expression
Many genetic disorders have a constellation of signs and symptoms, but not all individuals with the disorder will _______ them. These disorders exhibit what is termed variable expression.: manifest
Expression refers to the components of the _______ that are exhibited in an individual.: phenotype
Two gene types?: structural genes
regulatory genes
What is a structural gene type?: code for one particular gene product (protein) that performs a function elsewhere in the cell or body
What is a regulatory gene?: code for a gene product that regulates the expression of another gene(s)
What is gene expression?: activation of a gene leading to transcription, translation, and synthesis of a specific protein
What is gene suppression?: suppression of a specific gene activity through the action of a regulatory gene
OR
through changing conditions at the cellular level

the action prevents protein synthesis by inhibiting the process of gene transcription
Which type of genes may mutate to cause cancer?: tumour suppressor genes
oncogenes
DNA repair genes
telomerase
p53
Genes implicated in cancer: tumor suppressor genes?: normal function is to suppress or negatively regulate cell proliferation (function as BRAKES)

recessive , in that both alleles lost in cancer cells

examples:
RB gene, Retinoblastoma
TP53, lung, breast,
esophageal, liver,
bladder and ovarian;
brain, sarcomas,
lymphomas, leukemias
Overall - 50% human Ca
BRCA1 and 2, familial
breast, ovarian
oncogene classification?: growth factors
growth factor receptors
nonreceptor tyrosine kinase
(TK)
Growth factors?: vascular endothelial growth factor (VEGF) involved in tumor neoangiogenesis; fibroblast growth factor (FGF) in hemangiomas; platelet-derived growth factor (PDGF), sarcomas, gliomas
Growth factor receptors?: epidermal growth factor receptor (EGFR) (NSSLC, breast, ovarian, colorectal, H & N), ERBB2, (ovarian and breast), TGFB
Nonreceptor Tyrosine Kinase (TK)?: SRC gene family initiate TK activity, increased in neuroblastoma, SCLC, colon and breast adenocarcinoma
Define telomeres?: These are the extreme ends or "tips" of a chromosome

Within these structures are multiple repeat sequences

As a person ages, the telomeric areas of chromosomes become shorter
What role do telomeres play in cancer development?: these areas appear to play a role in cancer development in that many cancer cells retain their telomeric lengths and have minimal limits placed on their reproductive capacity

activation of enzyme telomerase
"immortality"
lose programmed cell death.
Types of genetic alterations in cancer?: amplification
chromosomal abnormalities
defects in mismatch repair
mutations
Define mutations?: mutations may arise during DNA replication and recombination, be caused by mutagens, or arise spontaneously
Chromosomal abnormalities?: fragile sites on chromosomes may explain resulting abnormal cell growth

fragile sites are sensitive to low folic acid

can be induced by mutagens and carcinogens

have been implicated in cancer....multiple myeloma (MM) and Chronic Lymphocytic Leukemia (CLL)
Amplification?: increase in number of gene copies

results in overexpression of gene product

amplification of certain genes may relate to carcinogenesis...
ex: enhancement by ultraviolet light

progression of tumor cells results in loss of cell-cycle control, loss of TS gene activity and increased amplification,
Ex: HER2?NEU
Define aneuploidy?: the karyotype of tumor cells can, in some situations, be useful in either diagnosing specific malignancies or have prognostic value for response to therapy

overall, the more abnormal the tumor karyotype, the more advanced the tumor usually is
Hallmarks of hereditary cancers?: breast cancer
BRCA1
BRCA2

colorectal cancer
HNPCC
Familial Adenomatous
Polyposis (FAP)

Multiple Endocrine Neoplasia
(MEN)
Population base characteristics: founder effect...high frequency of a gene mutation in a population founded by a small ancestral group when one of the founders was a carrier of the mutation, for ex.

occurs when there is little influx of outside individuals resulting in the wide distribution of a limited number of different chromosomes among a population
Familial adenomatous polyposis (FAP)?: APC gene on chromosome 5

numerous adenomatous polyps
(greater than 100)
extra-intestinal features

polys develop during teen
years

90% penetrance by age 30
MEN 2A?: thyroid cancer - 90%
involement of parathyroid -
10-20%
phenochromocytoma
40-60%
curable if detected prior to
metastasis
MEN 2B?: thyroid cancer
pheochromocytoma
mucosal neuromas
Cancer sites with inherited risk component?: skin
prostate
nephroblastoma
retinoblastoma
Wilm's tumor
Li-Fraumeni syndrome

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