Cancer

1. Cancer Lake Sumter Community College Irene Owens MSN, FNP Fall 2010

2. Cancer Statistics (NCI, 2003 a; WHO, 2003) Cancer rates will increase by 50% to 15 million new cases in 2020. The three leading cancer killers worldwide are lung, stomach, and liver cancers. Industrial nations with the highest overall cancer rates Developing countries with the lowest cancer rates Overall cancer incidence and mortality Statistics for mortality and incidence of all cancers vary by race, socioeconomic disparities and unequal access to medical car. Cancer rates vary relative to select demographic variables. 2

3. 2005 Estimated US Cancer Cases* Men710,040 Women662,870 • 32% Breast • 12% Lung & bronchus • 11% Colon & rectum • 6% Uterine corpus • 4% Ovary • 4% Non-Hodgkin lymphoma • 4% Melanoma of skin • 3% Thyroid • 2% Pancreas • 2% Urinary bladder • 20% All Other Sites Prostate 33% Lung & bronchus 13% Colon & rectum 11% Urinary bladder 6% Melanoma of skin 4% Non-Hodgkin lymphoma 4% Kidney 3% Oral Cavity 3% Leukemia 3% Pancreas 2% All Other Sites 18% *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2005.

4. 2005 Estimated US Cancer Deaths* Men295,280 Women275,000 Lung & bronchus 32% Prostate 10% Colon & rectum 10% Pancreas 5% Leukemia 5% Non-Hodgkin 4%lymphoma Esophagus 4% Liver & intrahepatic 3%bile duct Urinary bladder 3% Kidney 3% All other sites 21% • 25% Lung & bronchus • 15% Breast • 10% Colon & rectum • 6% Ovary • 6% Pancreas • 4% Leukemia • 3% Non-Hodgkin lymphoma • 3% Uterine corpus • 2% Multiple myeloma • 2% Brain/ONS • 24% All other sites ONS=Other nervous system. Source: American Cancer Society, 2005.

5. Cancer Death Rates*, by Race and Ethnicity, 1996-2000 *Per 100,000, age-adjusted to the 2000 US standard population. † Hispanic is not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians. Source: Surveillance, Epidemiology, and End Results Program, 1975-2000, Division of Cancer Control and Population Sciences, National Cancer Institute, 2003.

6. 9,000 new cases of childhood cancer 1,500 deaths One third die from leukemia 5 year survival for childhood cancer is 75% 10 year survival approaches 70%

7. Changing Cancer Statistics • Aging • Elderly will double from 1.3 to 2.6 million from 2000-2050 • Diversifying • 25% Hispanic • 25% African American, Asian American and Native Americans • 50% population ethnically and culturally diverse

8. Cancer Survival Increasing 9.3 million Americans have a cancer history Represents 3.4 % US population 14% diagnosed over 20 years ago

9. Development of Cancer

10. Cancer Development • Environmental Factors • ----Chemical: Tobacco, alcohol, asbestos, pesticides, hair dyes, preservatives, etc. • ----Physical: radiation, chronic irritation, sunlight • ----Viral: HPV

11. Cancer Development • Personal factors: age, immune factor, genetic risks, host susceptibility, lifestyle, risky health practices, gender, socioeconomic factors, race • Psychosocial Factors: Socioeconomic Factors: Barriers to access, poverty, no insurance, lack of education, lack of early detection

12. Normal Cells vs. Cancer Cells • Normal vs Cancer Cells • Page 402 in Iggy

13. Characteristics of Cancer Cells • Lack of contact inhibition • Inability to differentiate • Cancer cells derive from a single cell • Abnormal cellular proliferation • Local tumor formation • Invasion of surrounding tissue • Ability to metastasize

14. Pathophysiology of Cancer Development • Initiation: Normal cell exposed to any carcinogen ( initiator), the normal cell’s DNA can be damaged or mutated. A carcinogen is any chemical, physical, or genetic agent that can irreversibly alter cellular DNA, causing abnormal cells to be produced. Promotion: substance that promote or enhance growth of initiated cancer cell such as hormones, drugs or chemicals Progression- develops own blood supply

16. Promotion - Oncogenes • Oncogenes are genes that encode proteins to promote cellular proliferation • Oncogenes are derived from normal proto-oncogene • A proto-oncogene is essential for growth, proliferation, differentiation, apoptosis • Results in uncontrolled growth and replication of cells • Mutations in proto-oncogene yields uncontrolled growth-stimulatory proteins (deregulation)

17. Progression • Cancer cells divide uncontrollably • Tumors form and invade surrounding structures • Tumors form new blood vessels (angiogenesis) • Cancer cells can form new colonies (metastasis)

18. Tumor-Suppressor Genes • Normal braking signal to stop cellular division • Defect in tumor suppressor gene • Mutation causes inactivation or deletion of tumor-suppressor gene • Changes in • cell adhesion, signal transduction, nuclear transcription and cell cycle

19. Apoptosis – Programmed Cell Death • Unscheduled apoptosis occurs in Parkinson’s, Alzheimer’s and autoimmune disease • Defect in apoptosis occurs with cancer

20. Angiogenesis • Important in normal growth and development • wound healing and pregnancy • Cancer - critical for growth and spread of most cancers by forming new blood vessels • Target of anti-angiogenic therapy is normal endothelial cell rather than unstable tumor cell

21. Angiogenesis in Primary and Metastatic Tumors

22. Tumor Angiogenesis and Neovascularization

23. Comparison of Normal and Tumor Neovasculature Normal colorectal mucosa Nearby colorectal cancer From Konerding et al. In Molls and Vaupel, eds. Blood Perfusion and Microenvironment of Human Tumors, 2002, with permission.

24. Metastasis • Cells detach from original tumor • Cells spread through blood, lymphatics, or seeding • Cells establish new colony in distant site

25. Routes of Tumor Spread • Direct • Metastatic • Lymphatic

26. Common Sites of Metastasis • Bone • Lung • Liver • Brain

27. Nursing Assessment • Risk Factors • Lifestyle Factors • Family History • Signs/symptoms of Cancer • ----- (7 warning signs)

28. 7 Warning Signs of Cancer • C • A • U • T • I • O • N

29. Prevention of Cancer • Lifestyle Changes • DO NOT SMOKE! • STOP SMOKING!! • Minimize sun exposure • Avoid risky behaviors: ETOH abuse, multiple sex partners

30. Health Behaviors Dietary changes - 5 fruits/vegetables a day Exercise Know the 7 warning signs Control weight Decrease stress Practice self exam Stop or prevent smoking

31. Breast Cancer • Screening and Early Detection • Baseline mammogram by age 40 • Mammogram annually after 50 • Clinical Breast Exam every 3 years • Breast self-exam every month • High risk women need increased surveillance

32. Breast Cancer • 211,000 new cases • Most frequently diagnosed cancer in women • Second leading cause of cancer death • 40,480 expected deaths • Risk factors – advancing age, family history of breast cancer, atypical hyperplasia, long menstrual history, obesity after menopause

33. Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society • Yearly mammograms are recommended starting at age 40. • A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older. • Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s. • Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

34. Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society • Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age. • Screening should be done every year with regular Pap tests or every two years using liquid-based tests. • At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more frequently if she has certain risk factors, such as HIV infection or a weakened immune system. • Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening. • Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.

35. Prostate Cancer • Screening & Early Detection • Digital rectal exam every year after age 50 • PSA every year after age 50 • Increased surveillance of high risk men particularly African Americans

36. Prostate Cancer • 220,900 new cases and 28,900 deaths in 2003 • Early prostate cancer has no symptoms • Risk factors: age, AA, family history • Treatment: surgery, radiation, hormone therapy, watchful waiting

37. Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society • The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years. • Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45. • For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.

38. The American Cancer Society’s Estimates • In the United States during 2008: • 215,020 new cases of lung cancer will be diagnosed. • 161,840 deaths will occur as the result of this disease. Lung Cancer

39. Lung Cancer • Persistent cough, blood-streaked sputum, chest pain • Cigarette smoking most common cause

40. Colorectal Cancer • 105,500 colon; 42,000 rectal; 57,100 deaths • 3rd most common cancer • No symptoms in early stages • Hereditary Non-polyposis colorectal cancer and NPC (non-polyposis) are hereditary)

41. Screening Guidelines for the Early Detection of Colorectal Cancer, American Cancer Society • Beginning at age 50, men and women should follow one of the following examination schedules: • A fecal occult blood test (FOBT) every year • A flexible sigmoidoscopy (FSIG) every five years • Annual fecal occult blood test and flexible sigmoidoscopy every five years* • A double-contrast barium enema every five years • A colonoscopy every ten years • *Combined testing is preferred over either annual FOBT or FSIG every 5 years alone. People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule

42. Testicular Cancer • The American Cancer Society estimates that about 8,090 new cases of testicular cancer will be diagnosed during 2008 in the United States. It is estimated that 380 men will die of testicular cancer in 2008. The rate of testicular cancer has been increasing in many countries, including the United States.

43. Testicular Exams • The best time to examine is after a shower. Hold the penis out of the way and examine each testicle separately.  • Hold the testicle between your thumbs and fingers with both hands and roll it gently between the fingers.  • Look and feel for any hard lumps or nodules (smooth rounded masses) or any change in the size, shape, or consistency of the testes.

44. Diagnosis • The ideal is to find early ( a few cells) • ---Detectable at 1 cm ( 10 billion cells)

45. Diagnostic Studies • Routine Screenings • Biopsy • Tumor Markers

46. Diagnosis of Cancer • Cytology Studies • CXR • CBC • Sigmoidoscopy or colonoscoy • LFTRadiologic studies • Radioisotpoe scans • CT • MRI • CEA, AFP, CA-27-29, BRCA-1 BRCA-2 • Bone Marrow • Biopsy

47. Biopsy • Definitive means of diagnosing • Benign or malignant, the anatomic tissue, the degree of cellular differentiation of the cancer cells present. Differentiate needle vs incisional vs. excisional biopsy

48. Epithelium carcinoma adenocarcinoma Connective fibrosarcoma osteosarcoma Blood leukemia Lymphoid lymphomas Hodgkin’s disease Neural glioblastoma Tumor Classifications

49. Staging of Cancer • Page 407 Iggy Table 23-7

50. TNM Classification System • Table 23-7 Staging of Cancer • Grading of Cancer Table 23-6 • Staging vs. Grading