Prevention, Screening, and Early Detection of Cancer *There are three interrelated activities involved in cancer prevention and

control 1. Prevention- involves measures to avoid or reduce exposure to carcinogens 2. Screening- helps in identifying high risk populations and individuals. 3. Early Detection- diagnosing a cancer at its earliest, most treatable usage PRIMARY PREVENTION - Is concerned with reducing the risks of disease through health promotion strategies (identifying the risk factors such as race, culture, access to care, patient-physician and patient-nurse relationships, level of education, and age that influences knowledge, attitudes, and beliefs about cancer). - Also one way to reduce the risk of cancer is to help patients avoid known carcinogens. - Another strategy involves encouraging patients to make dietary and lifestyle changes (smoking cessation, decreased caloric intake, increased physical activity. SECONDARY PREVENTION - Programs that promote screening and early detection activities such as breast and testicular self examination and Papanicolaou (Pap) tests. - These events offer education and examinations such as mammograms, digital rectal examinations and PSA blood tests. Also it includes the understanding of the role of genetics in cancer cell development which have been a contribution to prevention and screening efforts PREVENTION AND EARLY DETECTION OF COMMON CANCERS Breast Cancer *Risk factors: early menarche, late menopause, nulliparous or older than 30 years at the birth of the first child. Breast cancer mortality could be reduced by 30% through early detection using routine screening mammography or annual clinical breast examination beginning 40 and 50 years of age. Breast Self Examination (BSE) - women should perform this monthly beginning at 20 years of age *Tamoxifen- effective chemopreventive for breast cancer Lung Cancer - Most commonly occurring cancer and the leading cause of cancer deaths worldwide *Risk Factor: tuberculosis (scar tumor), asbestos exposure, exposure to radiation and air pollution. Counseling clients ot to smoke, which will have the greatest effect on decreasing the rate of lung cancer. A healthy diet with at least 5 servings of fruit and vegetables is an added preventive step. Colorectal Cancer *Risk Factors: familial polypopsis, familial non-polypopsis syndromes, cancer family syndrome, hereditary site-specific colon cancer, and ulcerative colitis. Alcohol consumption,

smoking and a sedentary lifestyle are also contributing factors. Although a weaker risk factor associated with colorectal cancer may be a high fat or low fiber diet. There is no known prevention, although a healthy diet (high fiber, low fat, vitamins C and E, calcium, and folic acid) and physically active lifestyle may be of benefit. Research suggests that some pharmaceutical agents such as cyclooxygenase-2 (COX-2) inhibitors and aspirin may provide some protection. Early detection through routine screening is the key to decreasing mortality. It is recommended that people with an average risk should be screened annually with digital rectal examination and FOBT (40 y/o with sigmoidoscopy every 3 to 5 years beginning 50 y/o). Prostate Cancer *Risk Factor: Age (70 years old), family history and occupationally related risk factor is exposure to cadmium. Prevention strategies includes in limiting the exposure of workers handling cadmium batteries and keeping the intake of dietary fat low. ACS recommends that men age 50 years and high risk clients at age 40 years begin receicing digital rectal examination in addition to a prostate specific-antigen (PSA) blood test Cervical Cancer *Risk Factor: sexual behaviour and sexually transmitted infections, first intercourse at an early age, multiple sexual partners, or a sexual partner who has had multiple sexual partners. HPV, AIDS and smoking. Preventing cervical cancer includes changing of sexual behaviour, avoiding tobacco use, and undergoing routine screening. Pap Smear detects cancer in a premalignant stage when it is very amenable to treatment. The ACS recommends that cervical cancer screening begin 3 years after the onset of vaginal intercourse but no later than age 21. Head and Neck Cancer *Risk Factor: smoking, alcohol consumption, poor oral hygiene, long term sun exposure, and occupational exposure (asbestos, tar nickel, textile, wood or leather work, and machine tool operation) All clients who smoke or combine smoking with drinking alcohol should be counselled to stop these behaviours. Retinoids have been used as a chemopreventive Skin Cancer Non-Melanoma Skin Cancer (NMSC) Risk Factor: increase outdoor activities, changes in clothing styles, increased longevity, and ozone depletion. Melanoma Risk Factor: individuals with fair complexion, a family history, multiple or atypical nevi (moles), and occupational exposure to coal tar, pitch, creosote, arsenic or radium Prevention involves avoiding ultraviolet radiation as well a s limiting, mid day sun exposure, wearing a hat or clothing to protect the skin, using a sunscreen with a sun protective factor (SPF) of 15 or higher.

RECOMMENDATION FOR THE EARLY DETECTION OF CANCER. Cancer Site Breast Population Women, aged 20 years Test or Procedure - Breast Self Examination (BSE) Frequency - at early 20s, women should be told about the benefits and limitations of BSE. It is acceptable for women to choose not to do BSE or to do BSE irregularly. - It is recommended for women in their 20s-30s to have CBE and to be a part of a periodic health examns at least every 3 years. For 20 years they should do it annually. - Annual mammography at age 40 years - Annual/ every 5 years starting at age 50 years Annual FOBT or FIT and flexible sigmoidoscopy every 5 years, starting at age 50 years DCBE, every 5 years, starting at age 50 years Colonoscopy, every 10 years, starting at age 50 years PSA test and DRE should be offered annually, starting at age 50 years Should star approx. 3 years after a woman begins having vaginal

- Clinical Breast Examination (CBE)

- Mamography

Colorectal

Men and women, aged 50 years

- Fecal Occult Blood Test (FOBT), or Fecal immunochemical Test (FIT) or flexible sigmoidoscopy or Contrast Barium Enema

Prostate

Men, aged years

50

Cervix

Women, aged years

18

Digital Rectal Exam. (DRE) and Prostatespecific Antigen (PSA) test Pap test

Endometrial

Women, at menopause

Cancer-related checkup

Men and women, aged 20 years

intercourse, but no later than age 21 years. Test should be done every year. At or after 30 years get screened every 2-3 yrs. with cervical cytology. Women at average risk should be informed about risks and symptoms of endometrial cancer and strongly encourage to report any unexpected bleeding or spotting. On the occasion of a periodic health examination, the cancer- related check-up should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes as well as health counselling about tobacco, sun exposure, diet and nutrition etc.

DIAGNOSIS OF CANCER - It is based on assessment of physiologic and functional changes and results of the diagnostic evaluation. - It involves review of systems, physical examination, imaging studies, lab tests of blood, urine and other body fluids, and surgical and pathology reports. * Patient with suspected cancer undergoes extensive tests to: - determine the presence and extent of tumor - identify possible spread (metastasis) of disease or invasion of other body tissues. - evaluate the function TUMOR STAGING AND GRADING GRADING AND STAGING OF CANCER When a neoplastic growth is definitely diagnosed, it must be further defined in terms of its degree of malignancy (grade) and extent of spread (stage). Staging determines the size of the tumor and the existence of local invasion and distant metastasis. Grading refers to the classification of the tumor cells. Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation). Samples for this system may be obtained from tissue scrapings, body fluids, secretions, or washings, biopsy, or surgical excision. Grade GX G1 G2 Interpretation Grade cannot be assessed (Undetermined grade) Well-differentiated (Low grade) Moderately differentiated (Intermediate grade)

G3 Poorly differentiated (High grade) G4 Undifferentiated (High grade) of involved and uninvolved body systems and organs - obtain tissue and cells for analysis including evaluation of tumor stage and grade Cancer Staging determines the extent of disease and is used in treatment decision making. Staging involves a systematic research for the characteristic of the primary tumor (T), involvement of lymph nodes (N), and evidence of metastasis (M). TNM Staging System Stage TX T0 Tis T1, T2, T3, T4 NX N0 N1, N2, N3 MX M0 M1 Classification Primary Tumor (T) No primary tumor can be assessed No evidence of primary tumor Carcinoma in situ Increasing size and extent of primary tumor Regional Lymph Nodes (N) Cannot be assessed No regional lymph node involvement Increasing involvement of regional lymph node Distant Metastasis (M) Presence of metastasis cannot be assessed No distant metastasis Distant Metastasis

MANAGEMENT/TREATMENT OF CANCER RADIATION THERAPY - It may be used to cure cancer like thyroid carcinomas, localized cancers of the head and the neck, and cancers of the uterus and the cervix - Used to control malignant disease when a tumor cannot be removed surgically or when local nodal metastasis is present - Main goal of XRT is to destroy the cancer while keeping dosages within the normal tissue tolerance to avoid harming surrounding normal tissues. - XRT may be used as a primary, adjuvant, neoadjuvant, prophylactic or palliative treatment. - Primary modality, only treatment used and aims to achieve local cure of the cancer - Adjuvant Treatment, used either preoperatively or postoperatively to aid in the destruction of cancer cells - It can also be used neoadjuvantly (prior to local definitive treatment) with or without chemotherapy to reduce the size of the tumor to enable surgical resection. - May be used prophylactically to prevent the spread of primary cancer to a distant area - Palliative radiation therapy- used to relieve the symptoms of metastatic disease, especially when the cancer has spread to the brain, bone or soft tissues.

2 Types of ionizing radiation 1. Electromagnetic radiation- x-rays and gamma rays 2. Particulate Radiation- electrons, beta particles, protons, neutrons and alpha particles *** both can lead to tissue disruption **Ionizing radiation breaks the strands of the DNA helix, leading to cell death. **It is important to remember that radiation therapy is localized treatment, and only the tissues that are within the treatment field will be affected by the radiation therapy. Radiation Dosage - depends on the sensitivity of the target tissues to radiation, the size of the tumor, tissue tolerance of the surrounding normal tissues, and critical structures adjacent to the tumor target. - The lethal tumor dose is defined as that dose that will eradicate 95% tumor yet preserve normal tissue. How Radiation Therapy Works? - Radiation Therapy is the use of high energy ionizing radiation to treat a variety of cancers. Ionizing radiation destroys a cells ability to reproduce by damaging its DNA, delaying mitosis to repair DNA, or inducing apoptosis. - Radiosensitivity (relative susceptibility of tissues to radiation, depends on the individual cells) depends on the individual cells and the characteristics of the tissue itself. - A highly radiosensitive tumor is greatly affected by radiation because it divides rapidly, well vascularised, and has high oxygen content. Administration of Radiation - Can be administered in a variety of ways depending on the source of radiation used, location of the tumor and the type of cancer targeted. - The primary applications include teletherapy (external beam radiation), brachytherapy (internal radiation), systemic (radioisotopes) and contact or surface molds. External Radiation Therapy - External Beam Radiation Therapy (EBRT), most commonly used form of radiation therapy (e.g. GammaKnife). - These are able to shape an invisible beam of higly charged electrons to penetrate the body and target a tumor with pinpoint accuracy. - It will not only destroy the tumor, it will also spare the surrounding healthy tissue and vital organs - It also have a skin sparing effect Internal Radiation Therapy - Implantation, or brachytherapy, delivers a high dose of radiation to a localized area - It involves replacement of specifically prepared radioisotopes directly into or near the tumor itself (brachytherapy) or into the systemic circulation

It can be implanted by means of needles, seeds, beads, or catheters into body cavities or interstitial compartments

2 Major Types of Internal XRT 1. Sealed Source XRT- used for both intracavity and interstitial therapy - Radioisotope (Intracavity): Celsium-137 or radium-226 (24-72 hours) which is used to treat cancers of the uterus and the cervix. - Radioisotope (Interstitial): Iridium-192, iodine-125, cesium-137, gold-198 or radon-222) which is placed needles, seeds, beads, ribbons or catheters which are implanted directly to the tumor. It is used to treat prostate or breast cancer. 2. Unsealed Source XRT- used in systemic therapy. - Colloid suspension that come into direct contact with body tissues. - Radioisotopes: IV, PO or instillation directly into a body cavity. - Iodine-131, given in low doses for Graves Disease and high doses to treat thyroid cancer. Nursing Management in Radiation therapy - Assessment of skin and oropharyngeal mucosa regularly when this therapy is directed to this area. - Nutritional status - If systemic symptoms, such as weakness and fatigue occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease. Radiation Safety Standards The key principle in protecting oneself and others from excessive radiation exposure 1. Distance- > the distance from radiation source, < the exposure dose of ionizing rays 2. Time- Exposure time should generally be limited to 30 minutes of direct care per 8 hour shift. You need to plan your time in the clients room so you can spend it efficiently while providing care to the client. Care for the client should be rotated among available nursing staff to limit exposure for each employee. PREGNANT NURSES should NOT be assigned to care for clients receiving XRT 3. Shielding- helps reduce radiation exposure by using lead shield.

CHEMOTHERAPY - Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replication. - Used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation. - GOALS OF CHEMOTHERAPY: cure, control, palliation. - It can be used as Adjuvant Chemotherapy, after initial treatment (XRT or Surgery), chemotherapeutic drugs are used to eliminate the remaining submicroscopic cancer cells that are suspected to be still present.

Neoadjuvant therapy- preoperative use of chemotherapy to reduce the bulk and lower the stage of a tumor, making it amenable to surgery or possibly even cured with subsequent local therapy. Objective of chemotherapy: destroy malignant tumor cells without excessive destruction of normal cells

The Cell Cycle

G0 phase (resting stage): The cell has not yet started to divide. Cells spend much of their lives in this phase. Depending on the type of cell, G0 can last from a few hours to a few years. When the cell gets a signal to reproduce, it moves into the G1 phase. G1 phase: During this phase, the cell starts making more proteins and growing larger, so the new cells will be of normal size. This phase lasts about 18 to 30 hours. S phase: In the S phase, the chromosomes containing the genetic code (DNA) are copied so that both of the new cells formed will have matching strands of DNA. S phase lasts about 18 to 20 hours. G2 phase: In the G2 phase, the cell checks the DNA and gets ready to start splitting into 2 cells. This phase lasts from 2 to 10 hours. M phase (mitosis): In this phase, which lasts only 30 to 60 minutes, the cell actually splits into 2 new cells.

This cell cycle is important because many chemotherapy drugs work only on cells that are actively reproducing (not on cells in the resting phase, G0). Some drugs specifically attack cells in a particular phase of the cell cycle (the M or S phases, for example). Understanding how these drugs work helps oncologists predict which drugs are likely to work well together. Doctors can also plan how often doses of each drug should be given based on the timing of the cell phases. When chemotherapy drugs attack reproducing cells, they cannot tell the difference between reproducing cells of normal tissues (those that are replacing worn-out normal cells) and cancer

cells. The damage to normal cells can cause side effects. Each time chemotherapy is given, it involves trying to find a balance between destroying the cancer cells (in order to cure or control the disease) and sparing the normal cells (to lessen unwanted side effects).

How does chemotherapy work? To understand how chemotherapy works, it is helpful to understand the normal life cycle of a cell, or the cell cycle. All living tissue is made up of cells. Cells grow and reproduce to replace cells lost through injury or normal "wear and tear." The cell cycle is a series of steps that both normal cells and cancer cells go through in order to form new cells. This discussion is somewhat technical, but it can help you understand how doctors predict which drugs are likely to work well together and how doctors decide how often doses of each drug should be given. The cell cycle has 5 phases which are labelled below using letters and numbers. Since cell reproduction happens over and over, the cell cycle is shown below as a circle. All the steps lead back to the resting phase (G0), which is the starting point. After a cell reproduces, the 2 new cells are identical. Each of the 2 cells made from the first cell can go through this cell cycle again when new cells are needed. CLASSIFICATION OF CHEMOTHERAPEUTIC AGENTS It may be classified by their relationship to the cycle which is termed as cell-cycle specific agents. Chemotherapeutic agents that act independently of the cell cycle phases are termed cellnonspecific agents. It can also be classified by chemical group. These include the alkylating agents, nitrosoureas, antimetabolites, antitumor antibiotics, plant alkaloids, hormonal agents and miscellaneous agents ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTS May be administered in the hospital, OP Center, or home setting by topical, oral, IV, IM, SQ, arterial, intracavitary, and intrathecal routes. The route of administration depends on the type of agent; the required dose; and the type of location, and extent of tumor being treated. DOSAGE It is based primarily on the patients TBSA, prev. response to chemotherapy or radiation therapy and function of major organ systems. EXTRAVASATION Antineoplastic chemotherapeutic agents are additionally classified by their potential to damage soft tissue if they inadvertently leak from a vein.

Mild discomfort to tissue destruction, depending on whether the agent is classified as a nonvesicant, irritant, vesicant. Irritant agents induce inflammation reactions but usually cause no permanent tissue damage. Vesicants, if deposited into the SQ tissue, cause tissue necrosis and damage to underlying tendons, nerves and blood vessels - A substance that causes tissue blistering. - Vesicants are highly reactive chemicals that combine with proteins, DNA, and other cellular components to result in cellular changes immediately after exposure. Toxicity GI system: nausea and vomiting- most common side effect; stomatitis, mucositis, and diarrhea Hematopoietic System: myelosuppression (decrease of bone marrow), granulocytes, red blood cells and platelets and increase risk and temperature. Renal System: It can damage the kidneys, hyperkalemia, hyperphosphatemia and hypocalcemia. Monitoring of BUN, serum creatinine, creatinine clearance Cardiopulmonary system: it may result to pulmonary fibrosis Reproducive System: testicular and ovarian function can be affected resulting in possible sterility Neurologic System: Can affect the peripheral nervous system. Fatigue: side effects of chemotherapeutic agents Nursing Management for Chemotherapy Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put the patients risk for nutritional and fluid and electrolyte disturbances. Nurse should encourage an adequate fluid and dietary intake.