Cancer

4. Breast cancer
   • Risk factors:
     1. Women > age 50.
     2. Family history of breast cancer.
     3. Never bore children, or bore first child after age 30.
     4. Had breast cancer in other breast.
     5. Menarche before age 11.
     6. Menopause after age 50.
     7. Exposure to endogenous estrogens.
     8. Exposure to ionizing radiation.
     9. High alcohol and fat intake may increase risk.
   • Annual incidence: 181,600 new cases; 44,190 estimated deaths.
   • Assessment:
     1. Subjective data:
        • Burning, itching of nipple.
        • Reported painless lump.
     2. Objective data:
        • Firm, nontender lump or mass.
        • Asymmetry of breast.
        • Nipple - retraction, discharge.
        • Alteration in breast skin - redness, dimpling, ulceration.
        • Palpation reveals lump.
        • Diagnostic tests: mammography, needle biopsy, core biopsy, excisional biopsy - level of estrogen-receptor protein predicts response to hormonal manipulation of metastatic disease and may represent a prognostic indicator for primary cancer; carcinoembryonic antigen (CEA) useful with metastatic disease of the breast.
   • Analysis/nursing diagnosis:
     1. Risk for injury related to surgical intervention.
     2. Body image disturbance related to effects of surgery, radiation, or chemotherapy.
     3. Altered sexuality patterns related to loss of breast.
   • Nursing care plan/implementation:
     1. Goal: assist through treatment protocol.
        • Radiation - primary treatment modality; adjunctive, external, or implantation to primary lesion site or nodes.
        • Chemotherapy usually given in combinations.
          1. Cytotoxic agents to destroy tumor and control metastasis.
          2. Alkylating agents: cyclophosphamide (Cytoxan).
          3. Antitumor antibiotics: doxorubicin (Adriamycin).
          4. Antimetabolites: fluorouracil (5-FU); methotrexate (Amethopterine, MTX).
          5. Plant alkaloids: vincristine sulfate (Oncovin).
          6. Hormones to control metastasis, provide palliation: androgens, fluoxymesterone (Halotestin), testosterone (Teslac), diethylstilbesterol (estrogen).
          7. Antiestrogens: tamoxifen (Nolvadex) may be used after initial treatment.
          8. Cortisols: cortisone, prednisolone (Delta-Cortef), prednisolone acetate (Meticortelone), prednisone (Deltasone, Deltra).
        • Surgery.
          1. Preoperative:
             • Goal: prepare for surgery-types:
               • Lumpectomy (with or without radiation) - used when lesion is small; section of breast is removed (often accompanied by radiation therapy and then radium interstitial implant).
               • Simple mastectomy - breast removed, no alteration in nodes.
               • Modified radical mastectomy - breast, some axillary nodes, subcutaneous tissue removed; pectoralis minor muscle removed.
               • Radical mastectomy - breast, axillary nodes, and pectoralis major and minor muscles removed.
               • Reconstructive surgery - done at time of initial mastectomy or (most often) later, when other adjuvant therapy has been completed.
             • Goal: promote comfort.
               • Allow patient and family to express fears, feelings.
               • Provide correct information about diagnostic tests, operative procedure, postoperative expectations.
               • Patient may be hospitalized for 24 hours or less. Have telephone number available for questions. Make appropriate community referrals.
          2. Postoperative:
             • Goal: facilitate healing.
               • Observe pressure dressings for bleeding; will appear under axilla and toward the back.
               • Report if dressing becomes saturated; reinforce dressing as need; monitor drainage from Hemovac or suction pump.
               • Position: semi-Fowler’s to facilitate venous and lymphatic drainage; use pillows to elevate affected arm above right atrium, to prevent edema if nodes removed.
             • Goal: prevent complications.
               • Monitor vital signs for shock.
               • Use gloves when emptying drainage.
               • Maintain joint mobility - flexion and extension of fingers, elbow, shoulder.
               • ROM as ordered to prevent ankylosis.
               • If skin graft done, check donor site and limit exercises.
             • Goal: facilitate rehabilitation.
               • Encourage patient, significant others, and family to look at incision.
               • Involve patient in incisional care, as tolerated.
               • Refer to Reach to Recovery program of the American Cancer Society
               • Exercise program, hydrotherapy for postmastectomy patients, to reduce lymphedema.
   • Evaluation/outcome criteria:
     1. Identifies feelings regarding loss.
     2. Demonstrates postmastectomy exercises.
     3. Gives rationale for avoiding fatigue and avoiding constricting garments on affected arm; necessity for avoiding injury (cuts, bruises, burns) while carrying out activities of daily living.
     4. Describes signs and symptoms of infection.
     5. Demonstrates correct BSE technique.

Breast self-examination. (A) Examine breasts during bath or shower because flat fingers glide easily over wet skin. Use right hand to examine left breast and vice versa. (B) Sit or stand before a mirror. Inspect breasts with hands at sides, then raised overhead. Look for changes in contour or dimpling of skin. (C) Place hands on hips and press down firmly to flex chest muscles. (D) Lie down with one hand under head and pillow or folded towel under that scapula. (E) Palpate that breast with the other hand using concentric circle method. It usually takes three circles to cover all breast tissue. Include the tail of the breast and the axilla. Repeat with other breast. (F) End in a sitting position. Palpate the areola areas of both breasts, and inspect and squeeze nipples to check for discharge.

5. Uterine cancer (endometrial): originates from epithelial tissues of the endometrium; second only to cervical cancer as cause of pelvic cancer. Slow growing; metastasizes late; responsive to therapy with early diagnosis; Pap test not as effective - more effective to have endometrial tissue sample.
   • Risk factors:
     1. History of infertility (nulliparity).
     2. Failure of ovulation.
     3. Prolonged estrogen therapy.
     4. Obesity.
     5. Menopause after age 52.
     6. Diabetes.
   • Annual incidence: 37,400 new cases; 6400 estimated deaths.
   • Assessment:
     1. Subjective data:
        • History of risk factor(s).
        • Pain (late symptom).
     2. Objective data:
        • Obese.
        • Abnormal cells obtained from aspiration of endocervix or endometrial washings.
        • Postmenopausal uterine bleeding.
        • Abnormal menses; intermenstrual or unusual discharge.
   • Analysis/nursing diagnosis:
     1. Pain related to surgery.
     2. Risk for injury related to surgery.
     3. Body image disturbance related to loss of uterus.
   • Nursing care plan/implementation:
     1. Goal: assist patient through treatment protocol.
        • Radiation - external, internal, or both with poor surgical risk patient.
        • Chemotherapy - to reduce tumors and produce remission of metastasis. Antineoplastic drugs: dacarbazine (DTIC), doxorubicin (Adriamycin), medroxyprogesterone acetate (Provera), megestrol acetate (Megace).
     2. Goal: prepare patient for surgery - types:
        • Subtotal hysterectomy: removal of the uterus; cervical stump remains.
        • Total hysterectomy: removal of entire uterus, including cervix (abdominally [approximately 70%] or vaginally).
        • Total hysterectomy with bilateral salpingooophorectomy: removal of entire uterus, fallopian tubes, and ovaries.
     3. Goal: reduce anxiety and depression: allow for expression of feelings, concerns about feminity, role, relationships.
     4. Goal: prevent postoperative complications.
        • Catheter care - temporary bladder atony may be present as a result of edema or nerve trauma, especially when vaginal approach is used.
        • Observe for abdominal distention and hemorrhage:
          1. Auscultate for bowel sounds.
          2. Measure abdominal girth.
          3. Use rectal tube to decrease flatus.
        • Decrease pelvic congestion and prevent venous stasis.
          1. Avoid high Fowler’s position.
          2. Antiembolic stockings as ordered.
          3. Institute passive leg exercises.
          4. Apply abdominal support as ordered.
          5. Encourage early ambulation.
     5. Goal: support coping mechanisms to prevent psychosocial response of depression: allow for verbalization of feelings.
     6. Goal: health teaching to prevent complication of hemorrhage, infection, thromboemboli.
        • Avoid:
          1. Douching or coitus until advised by physician.
          2. Strenuous activity and work for 2 months.
          3. Sitting for long time and wearing constrictive clothing, which tend to increase pelvic congestion.
        • Explain hormonal replacement if applicable; correct dosage, desired and side effects of prescribed medications.
        • Explain:
          1. Menstruation will no longer occur.
          2. Importance of reporting symptoms, e.g., fever, increased or bloody vaginal discharge, and hot flashes.
   • Evaluation/outcome criteria:
     1. Adjusts to altered body image.
     2. No complications - hemorrhage, shock, infection, thrombophlebitis.

International System of Staging for Cervical Carcinoma

Stage	Location	Prognosis	Treatment
0	In situ	Highly curable	Conization
I	Cervix	Cure rate decreases as stage progresses	Radiation
II	Cervix to upper vagina		Radiation
III	Cervix to pelvic wall or lower third of vagina		Surgeries: Panhysterectomy, wide vaginal excision with removal orlymph nodes; ileal conduit Pelvic exenteration: Anterior: removal of vagina and bladder; ileal conduit Posterior: removal of rectum and vagina; colostomy Total: both anterior and posterior Chemotherapy
IV	Cervix to true pelvis, bladder, or rectum

6. Prostate cancer: malignant neoplasm, usually adenocarcinoma; most common cause of cancer in men.
   • Risk factors:
     1. Men > age 50.
     2. Familial history.
     3. Geographic distribution, environmental (e.g., industrial exposure to cadmium).
     4. Hormonal factors (testosterone).
     5. Diet (high fat).
   • Annual incidence: 185,000 new cases; 40,000 estimated deaths.
   • Assessment:
     1. 1. Subjective data:
        • Difficulty in starting urinary stream (hesitancy); urgency.
        • Pain due to metastasis in lower back, hip, legs; perianal or rectal discomfort.
        • Symptoms of cystitis; frequency, urgency.
     2. Objective data:
        • Urinary: smaller, less forceful stream; terminal dribbling; frequency, nocturia; retention (inability to void after ingestion of alcohol or exposure to cold).
        • Diagnostic tests: digital rectal examination (DRE); transrectal ultrasonography (TRUS). Needle biopsy or tissue specimen reveals positive cancer cells.
        • Lab data: increased:
          1. Prostate-specific antigen (PSA) - over 4 ng/mL.
          2. Urine RBCs (hematuria).
          3. Gleason score for prostate cancer grading system (range: 2-10).
   • Analysis/nursing diagnosis:
     1. Altered urinary elimination related to incontinence.
     2. Altered sexuality pattern related to nerve damage and erectile dysfunction.
     3. Anxiety related to diagnosis.
     4. Pain related to metastasis to bone.
   • Nursing care plan/implementation:
     1. Goal: assist patient through decisions about treatment protocol (varies by stage: 0-IV).
        • Radiation - alone or in conjunction with surgery. Types: external beam radiation, 3-D conformal (focal), radioactive seed implants (brachytherapy).
        • Surgery - cryosurgery; radical retropubic prostatectomy.
        • Other options: hormones (luteinizing hormone-releasing hormone agonists [Lupron, Zoladex, Casodex, Nilandron]), antiandrogen (flutamide [Eulexin]); drugs in conjunction with orchiectomy, to limit production of androgens (androgen deprivation therapy).
        • Watchful waiting - recommended with small contained tumor; older men; where surgery is contraindicated for other serious health problems.