Week 10 Neoplasia

Question 1

Neoplasia

Answer 1

Neoplasia is the uncontrolled and abnormal growth of cells in the body that leads to the formation of tumours, or neoplasms. This growth will be excessive, uncoordinated and exceed the growth of surrounding tissue.
Neoplasms can be divided into two types, benign or malignant.

Benign neoplasms do not grow aggressively, do not invade the surrounding body tissues, and do not spread throughout the body.
Malignant neoplasms, on the other hand, tend to grow rapidly, invade the tissues around them, and spread, or metastasize, to other parts of the body.

Question 2

Malignant Tumour

Answer 2

A mass of non-structured, new cells that invade the basement membrane and have no known purpose in the physiological function of the body. Using the vascular system, lymphatic system or through seeding and implantation, these cells will grow, invade and spread to neighbouring organs and tissues, usually causing death.

Question 3

Benign tumour

Answer 3

New, abnormal mass of cells that do not invade unrelated tissues or organs, but may continue to grow in size abnormally. Complete recovery is expected after excision.

Question 4

Metastasis

Answer 4

The spread of cancer cells from the site of the original tumour to distant tissues and organs throughout the body.

Question 5

Staging

Answer 5

Classifying the extent and spread of the disease. Based on the anatomical extent rather than the cell appearance. Multiple cancers can use the same staging classifications.

Clinical Staging = stages 0, I, II, III, IV

TNM Classification system = tumour-node-metastasis

Question 6

Lymphoedema

Answer 6

Occurs when lymphatic channels are blocked or surgically removed, and proteins and fluid accummulate in the interstitial spaces.

Question 7

Palliative care

Answer 7

A coordinated approach to care that is both person- and family-centered, aimed at opitimising the quality of life for a terminally ill person with an active, progressive and advanced disease.

Question 8

End of life care

Answer 8

An approach to health care which is provided in the hours, days or months before a person dies, once treatment to cure or control their life-limiting disease has stopped. This care aims to address the mental and emotional needs, physical comfort, spiritual needs and practical social needs of a dying person and their family/support.

Question 9

Breast Cancer

Answer 9

For women, breasts are made up of milk producing lobules, ducts which carry the milk and fatty connective tissue which surrounds the lobules and ducts. For men, their breasts consist mainly of fatty connective tissue surrounding a small amount of ductal tissue.

Breast cancer occurs when abnormal cells in breast tissue grow in an uncoordinated and uncontrolled way and invade local tissue. It can occur at any age, but is more likely to occur in older adults and it can affect both women and men.

Question 10

Risk Factors for Breast Cancer

Answer 10

Gender
Being a woman is the single, biggest risk factor → most common type of cancer affecting women

Risk concurrently increases with age and, for women, diagnosis most commonly occurs after menopause.
Up to 1000 women <40 years were diagnosed with breast cancer in 2022

Family history
Risk increased with first degree or second degree relative on same side of the family

Genetics
Single gene mutation from mother or father increases risk by 5-10%
Highest risk associated with mutations of 2 genes → BRCA1 (breast cancer gene one) and BRCA2 (breast cancer gene two)
For men, risk increased with Klinefelter syndrome

Reproductive risk factors
Early menarche → younger than 12 years
Delayed menopause → older than 55 years
Delayed age at first pregnancy → women who haven’t had a full-term pregnancy until after the age of 30 years
Number of times a woman has given birth
Testicular abnormalities and gynecomastia

Modifiable risk factors
Obesity
Smoking
High alcohol intake

Endogenous and exogenous oestrogen
Oral contraceptive pill (OCP) → until 10 years after stopping it, especially if an older woman with a faulty gene is taking the OCP.
Menopause hormonal therapy (new term for hormone replacement therapy) → increased when combined with progesterone and taken for >5 years

Question 11

Non-Invasive Breast Cancers

Answer 11

Non-invasive breast cancers are contained in the milk ducts or lobules within the breast and have not grown into or invaded normal breast tissue. They include:

Ductal carcinoma insitu [DCIS] → most common→ starts in the milk ducts → not considered life threatening.
Lobular carcinoma insitu [LCIS] → grows in the lobules → not considered life threatening but can lead to the risk of developing breast cancer later in life.

Question 12

Invasive Breast Cancers

Answer 12

Most common type of breast cancer:

Invasive Ductal Carcinoma (IDC) → 80% of all breast cancers → can spread to lymph nodes and potentially other parts of the body.
Invasive Lobular Carcinoma (ILC) → second most common breast cancer → mass develops in lobules and invades the basement membrane, spreading into surrounding breast tissue, lymph nodes and other parts of the body.
Paget’s disease of the nipple → rare → cancerous cells grow in the nipple or areola → nipple becomes scaly red, itchy and irritated.
Inflammatory breast cancer → rare and aggressive → fast growing cancer with high risk of metastasis → lymph channels in the skin become blocked → breast becomes erythematous, warm to touch and with a thickened appearance.
Metastatic breast cancer → aggressive and fast growing → spreading to bones, lungs, liver, lymph nodes and brain.

Question 13

The clinical manifestations of breast cancer can vary from being asymptomatic to any of the following:

Answer 13

On self examination, a non-tender and fixed breast nodule can be palpated that is approximately 1cm in size.
Pain → any unusual pain in the breast or axilla that does not go away.
Lump or thickening → inside the breast or axilla
Asymmetrical changes in breast size and shape
Unusual nipple discharge → clear or bloody and is not breast milk
Change in the nipple such as nipple retraction, dimples, burning or itching (rash)
Flaky, thickened or discoloured skin of the breast
Dimpled, pulled or retracted area of the breast

Question 14

Diagnosis
It is recommended that doctors use the triple test approach in the diagnosis of breast cancer:

Answer 14

a comprehensive history and clinical breast examination;

imaging → mammogram +/- ultrasound scan

a biopsy → fine-needle aspiration biopsy, vacuum-assisted core biopsy, large-core surgical biopsy or an open surgical biopsy.

Question 15

Stages of breast cancer

Answer 15

Stages of breast cancer are numbered 0 - IV:

Stage 0 → ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)
Stage I, IIA and IIB → early stages of breast cancer
Stage IIB, IIIA, IIIB, IIIC and IV → signify advanced (metastatic) breast cancer.
Another approach to staging breast cancer is by using the TNM system

T → tumour size
N → Lymph node status
M → Metastasis

Question 16

Treatment
Breast cancer

Answer 16

Treatment
Breast cancer is not a singular disease → there are several types and subtypes, and treatment options differ with each on. Treatment options are most often based on the histopathology and stage of the cancer. Other factors such as age, pre-existing co-morbidities, logistics, costs and individual preferences are also considered. Most people will have multimodal treatments which consist of:

Surgery
Radical mastectomy: Removes entire breast, axillary lymph nodes and pectoral muscles
Partial mastectomy: Removes the tumour/lump and surrounding margin of normal tissue

Radiotherapy,

Antineoplastic agents,

Hormone therapy along with targeted therapy.

Clinical Trials are an important factor in the treatment of breast cancer as the trials are focused on finding new treatment options that are more effective than the current treatment available.

Question 17

Assessment of a patient with breast cancer needs to include the following:

Answer 17

Health history
Physical Assessment
Mental Health Assessment

Question 18

Nursing Management
breast surgery

Answer 18

Post-operative care following breast surgery includes:

Monitoring for risk of bleeding
Observe the wound and dressings
Monitor the drain
Monitor vital signs.

Minimising pain
Regular post operative pain assessments
Administer analgesia as charted
Your patient may have a PCA → complete PCA related observations as per guidelines
Altered sensation in the axilla is common → reassure the patient
Non-pharmacological interventions
Ice packs
Splinting with pillows / folded blankets

Monitoring for risks of infection (this is not relevant for the first 48 hours)
Regular vital signs
Wound assessment
Remove clips and sutures as directed → usually 5-10 days postoperatively
Remove wound drains as directed → usually 2 days postoperatively

Provide psychosocial support → patients usually experience profound changes in body image and sexual function
Allow the patient time to discuss fears and concerns
Refer the patient to a specialist counsellor
Provide advice on reconstruction or a prosthesis
Provide advice to family or significant other

Arm exercises following dissection of the axillary lymph nodes
Increased risk of decreased range of motion of the shoulder joint
Refer to physiotherapy early.

Manage arm lymphoedema
Educate patients on
Cause and signs
Preventing infections in the affected arm:
Signs & symptoms of infection
Use gloves when gardening or doing household cleaning
Avoid the use of razors other than electric razors
Self-care of open wounds
Moisturise the affected arm and hand
Carrying out arm and shoulder exercises
Elevate the affected arm, especially immediately post-operatively
Avoid carrying heavy objects with the affected arm
Avoid wearing heavy shoulder bags on the affected side
Avoid injections, blood testing and the use of a blood pressure cuff on the affected arm

Discharge advice
Seek medical help if signs of infection develop
Provide details for psychological support or support groups
Attend outpatient follow-up appointments

Question 19

Caring For Men with Breast Cancer

Answer 19

One of the most important factors in caring for men with breast cancer is their psychosocial well-being. Breast cancer is mainly considered as a woman’s disease which can lead to a health related stigmatisation. When caring for men with breast cancer, it is important that you are aware that this could be a concern for the patient in their care. The reading by Midding et al. (2018) will provide you with some insight to the stigmatisation that occurs when men are diagnosed with breast cancer.

Question 20

Lung Cancer

Answer 20

Lung cancer starts when abnormal cells rapidly multiply in an uncoordinated and uncontrolled way in one, or both, lungs. With time, these cells become a mass, or a tumour, and will invade surrounding lung tissue, which results in clinical manifestations associated with loss of lung function, such as dyspnoea and pulmonary chest pain.

A tumour may be found in the bronchi or in the spongy lung tissue, called epithelium. Because lung cancer arises from the epithelium of the respiratory tract, the term lung cancer excludes pulmonary tumours, such as sarcomas, lymphomas, blastomas and mesotheliomas.

A tumour that originates in a lung is known as a primary lung cancer. Tumours in the lung may also result from cancer which has spread through the vascular system from another part of the body such as the breast, bowel, or prostate. These cancers are called lung metastases.

Question 21

Lung cancer
Risk Factors

Answer 21

The development of lung cancer seems to be a result of repetitive carcinogenic stimuli, inflammation and irritation with lifestyle, environmental and biomedical factors being involved:

Lifestyle Factors → tobacco smoking stands as the single largest cause of lung cancer accounting for 90% of cases diagnosed in males and 65% in females. It is important to note that non-smokers with no identifiable risk factors can also develop lung cancer.

Environmental Factors
Passive smoking → people who live with a smoker increase their risk of developing lung cancer by up to 30%.
Occupational exposure → industrial and chemical carcinogens (asbestos, radiation, diesel fumes).
Air pollution.

Biomedical Factors
Family history of lung cancer → the risk increases if there is a direct family member (parent or sibling) with lung cancer, and this is further increased if there is more than one.
Medical history of previous lung disease → chronic bronchitis, emphysema, pulmonary TB
Older age → in 2011, the average age for diagnosis of lung cancer for women was 70 years and for men 71 years.

Question 22

Types of Lung Cancer

Answer 22

Non-small cell lung cancer (NSCLC)
Small cell lung cancer (SCLC)

Question 23

Non-small cell lung cancer (NSCLC)

Answer 23

Non-small cell lung cancer is the most common type of lung cancer, accounting for around 85% of cases. There are sub-types of non-small cell lung cancer. The most common are:

Adenocarcinoma - begins in mucus-producing cells and makes up about 40% of lung cancers. While this type of lung cancer is most commonly diagnosed in current or former smokers, it is also the most common lung cancer in non-smokers.

Squamous cell (epidermoid) carcinoma - commonly develops in the larger airways of the lung.

Large cell undifferentiated carcinoma - can appear in any part of the lung and are not clearly squamous cell or adenocarcinoma.

Question 24

Small cell lung cancer (SCLC)

Answer 24

Small cell lung cancer usually begins in the middle of the lungs and spreads more quickly than non-small cell lung cancer. It accounts for around 20% of lung cancers and is the most malignant form

Question 25

Primary Clinical Manifestations
The clinical manifestations of lung cancer are related to the location and spread of the neoplasm which can then present with systematic symptoms:

Answer 25

Chronic cough
Haemoptysis
Wheezing
Dyspnoea
Dull aching chest pain
Pleuritic pain
Dysphonia and/or dysphagia
Repeated respiratory infections

Question 26

Multi-System Clinical Manifestations
Systemic signs and symptoms of lung cancer can include the following:

Answer 26

Weight loss,
Anorexia,
Fatigue and weakness,
Clubbing of the fingers and toes,
Confusion,
Impaired gait and balance,
Headaches (brain metastasis),
Thrombocytopenia and anaemia (bone marrow metastasis)
Liver dysfunction and biliary obstruction, jaundice, anorexia and upper right quadrant pain (liver metastasis),
Bone pain, pathological fractures, spinal cord compression (bone metastasis).

Question 27

Diagnosis
There are a number of investigations used to diagnose lung cancer following a full medical history and physical examination. These can include:

Answer 27

Imaging → chest x-ray, CT scan, MRI, PET scan, bone scan, USS
Fine needle lung biopsy
Sputum cytology
Serum pathology
Fibre optic bronchoscopy → to view airways and take further biopsies
Video assisted thoracoscopy
Thoracentesis
Reparatory function test
Arterial blood gas

Question 28

Staging
Once a diagnosis is made, the stage of the disease progression needs to be determined to establish an optimal treatment plan.

Answer 28

Non-small cell carcinoma can be divided into 6 stages:

Occult (hidden) → cancer cells are found in sputum of other lung fluids, but is not yet seen in any other tests
Stage 0 (carcinoma in situ) → the cancer is found in the top layers of the cells in the airways → it has not spread to lymph nodes
Stages I (IA, IB) II (IIA, IIB) and III (IIIA, IIIB) → these stages all involve the cancer increasing in size and spreading to lymph nodes (stages II and III)
Stage IV → the cancer has spread to the other lung, or other organs such as brain, bone and liver

Small cell lung cancer is divided into 2 stages → for the purpose of treatment:

Limited stage → only 1 lung is affected (possible lymph node involvement) and can be treated with radiation
Extensive stage → cancer has spread widely to lymph nodes and distant organs.

Question 29

Treatment
After diagnosis and staging, the treatment for lung cancer depends on the type, size and rate of growth → may include the following:

Answer 29

Surgical therapy → aimed at removing as much of the tumour as possible before starting additional therapy.
Radiation therapy
Stereotactic body radiotherapy
Chemotherapy
Biological and targeted therapy
Other therapies → bronchoscopy laser therapy, photodynamic therapy, airway stenting, radio frequency ablation

Question 30

Nursing Management

Once a diagnosis of lung cancer has been confirmed, the patient faces uncertainty, and possibly extensive and radical medical treatment. Significant levels of distress, anxiety and depression have been reported by patients diagnosed with lung cancer, predominantly due to the stigma attached to a ‘smoking disease’ and the associated poor prognosis. Psychological interventions can assist in improving overall well-being and coping with the physical symptoms of disease and treatment. For people experiencing advanced lung disease, consideration should be given to emotional, social and spiritual concerns.

Answer 30

Post-operative complications → pain, haemorrhage, nausea, and vomiting
Biological and cytotoxic effects → nausea and vomiting, mucositis, diarrhoea, constipation, and fatigue
Effects of radiotherapy → skin reactions, oesophagitis → leads to poor nutrition and fatigue.

Nursing assessment is important in developing a care plan that can anticipate needs and offer support

Assessment for clinical manifestations → dyspnoea, recurrent infection, fatigue, pain, and weight loss → can guide targeted education and support
Collateral assessments → family, social and employment histories
Risk assessments → used to determine the level of support required at home and in the community in the short, medium, and longer term → outcomes can be used to initiate appropriate referrals

Question 31

Nursing care considerations:

Answer 31

Impaired gas exchange related to removal of lung tissue, altered oxygen supply, increased secretions, ineffective airway clearance and impaired chest movement

Pain related to surgical incision and procedure, presence of surgical drains or intercostal catheters

At risk for imbalanced nutrition related to effects of chemotherapy

Fear/anxiety related to situational crisis, threat to health status

Knowledge deficit regarding condition / prognosis related to unfamiliarity of resources, misinterpretation of information, lack of recall

Question 32

Impaired gas exchange related to removal of lung tissue, altered oxygen supply, increased secretions, ineffective airway clearance and impaired chest movement

Answer 32

reposition frequently to maximise lung expansion and drainage of secretions.

administer supplemental oxygen, as necessary, to maximise available oxygen particularly while ventilation is reduced (due to anaesthetic, pain, etc.)

encourage and assist with deep breathing and coughing to promote maximal ventilation and perfusion.

encourage hydration measures to facilitate airway clearance.

ensure patency of chest drain system to promote re expansion of remaining lung segments.

Question 33

Pain related to surgical incision and procedure, presence of surgical drains or intercostal catheters

Answer 33

complete regular pain assessments

assist with positioning and splinting

consider non-pharmacological options

encourage deep breathing exercises

administer analgesics as per medication chart

communicate with medical team if pain remains moderate to severe

Question 34

At risk for imbalanced nutrition related to effects of chemotherapy

Answer 34

ensure adequate protein intake to promote healing and prevent oedema.

advise people to eat small amounts of high calorie, high protein foods more frequently.

advise people to have adequate rest to conserve energy.

refer to dietician to change diet consistency if oesophagitis has occurred.

monitor weight and appetite.

Question 35

Fear/anxiety related to situational crisis, threat to health status

Answer 35

evaluate the person’s level of understanding.
acknowledge and validate their concerns and fears and encourage the expression of their feelings → often people need time to identify the feelings and express them.
provide the opportunity for questions and answer honestly as this establishes trust and decreases misinterpretation of information.
consider multi-modal education → pamphlets, hand-outs, lived experience resources
take note of behaviours that indicate acceptance of the disease and prognosis.
involve the patient and family in care planning to help in providing the feeling of control and independence.

Question 36

Knowledge deficit regarding condition / prognosis related to unfamiliarity of resources, misinterpretation of information, lack of recall

Answer 36

openly discuss diagnosis and prognosis as information is essential to enable the client and family to make informed decisions.
discuss necessity of follow up care as this is imperative to ensure optimal recovery, it also provides an opportunity to readdress concerns and questions.
identify resources that may assist the patient and family with their recover.