Cellular Regulation:

Exemplars
Colon Cancer and Breast Cancer

Exemplar: Colon Cancer

Colon Cancer
Of cancers that affect both men and women, colorectal cancer
is the second leading cause of cancer-related deaths in the
United States and the third most common cancer in men and
in women
In 2011 (the most recent year numbers are available)
135,260 people in the United States were diagnosed with colorectal
cancer, including 70,099 men and 65,161 women.
51,783 people in the United States died from colorectal cancer,
including 26,804 men and 24,979 women.

(http://www.cdc.gov/cancer/colorectal/statistics/index.htm)

Colon Cancer: Pathophysiology

Adenocarcinoma is the most common type of CRC
About 85% arise from adenomatous polyps
Tumors spread through the walls
of the colon into musculature and into the lymphatic and
vascular systems

Most common sites of metastasis

Regional lymph nodes

Liver
Lungs
Bones
Brain

Colon Cancer: Risk Factors

Risk factors

Age older than 50 years

Polyps of colon and/or rectum
Family history of colorectal cancer
Inflammatory bowel disease
Exposure to radiation
Diet: high animal fat and kilocalorie intake

Colon Cancer: Clinical

Manifestations
Insidious onset

Change in bowel habits

Unexplained weight loss
Vague abdominal pain
Rectal bleeding is most common
Alternating constipation and diarrhea
Change in stool caliber
Narrow, ribbon-like

Sensation of incomplete evacuation

Obstruction

Colon Cancer: Clinical

Manifestations
Weakness and fatigue
Iron-deficiency anemia and occult bleeding

Weight loss
Palpable mass
Complications

Obstruction
Bleeding
Perforation
Peritonitis
Fistula formation

Colon Cancer: Diagnostic Studies:

Regular screening for polyps and cancer
Colonoscopy Gold standard

Annual screening primarily for cancer

Fecal occult blood test (FOBT)

Fecal immunochemical test (FIT)
CBC to check for anemia
Coagulation studies
Liver function tests

CT scan or MRI of the abdomen

Carcinoembryonic antigen (CEA)

Colon Cancer
Collaborative Care: Surgery
Surgical goals

Complete resection of tumor

Thorough exploration of abdomen
Removal of all lymph nodes that drain the area
Restoration of bowel continuity
Prevention of surgical complications

Surgical therapy
Polypectomy during colonoscopy is used to resect colorectal cancer in situ
Successful when
Resected margin of the polyp is free of cancer
Cancer is well differentiated
No lymphatic or blood vessel involvement is apparent

Colon Cancer
Collaborative Care: Surgery
Colonic bacteria before surgery to
Prevent infection
Prevent abscess formation
Bowel cleanse
Oral antibiotics

Site of cancer dictates site of resection

Right or left hemicolectomy

Colon Cancer
Collaborative Care: Surgery
Three surgical options in rectal cancer
Local excision
Low anterior resection (LAR) to preserve sphincter function
Abdominal-perineal resection (APR) with a permanent
colostomy

Reasons for temporary colostomy

Perforation
Peritonitis
Hemodynamic instability

Colon Cancer: Collaborative Care

Chemotherapy
5-Fluorouracil (5-FU) plus folinic acid
Oral fluoropyrimidines (capecitabine [Xeloda]) have been found equally
effective

Targeted therapy
Angiogenesis inhibitors inhibit the blood supply to tumors
Bevacizumab (Avastin)
Ziv-aflibercept (Zaltrap)

Multikinase inhibitors block several enzymes that promote cancer growth

Regorafenib (Stivarga)

Block epidermal growth factor receptor

Cetuximab (Erbitux)
Panitumumab (Vectibex)

Nursing Process: Assessment

Health history:

Usual bowel patterns

Recent changes
Pain
Family history

Physical Exam:

General appearance
Weight
Abdominal shape
Bowel sounds
Stool hemoccult or guaiac

Nursing Process: Plan

The client will not experience complications related to
altered elimination pattern.
The client will demonstrate proper ostomy care and
management.
The client will verbalize feelings related to diagnosis and
prognosis.
The family and/or significant others will provide
adequate emotional and physical support for the client
upon discharge.
The client will make an informed choice related to
treatment options.

Nursing Process: Implementation

Acute Pain
Monitor for adequate pain relief
Ask the client to rate pain using scale of 0-10
Monitor analgesic effectiveness 30 minutes after
administration.
Assess incision for inflammation or swelling
Assess abdomen for distention, tenderness, bowel sounds
Administer analgesia before an activity or procedure
Assist with comfort measures
Splint incision with a pillow

Nursing Process: Implementation

Imbalanced Nutrition: Less Than Body Requirements
Assess nutritional status
Height and weight, laboratory data (serum albumin)
Refer to a dietitian or nutritionist

Assess readiness for resumption of oral intake after surgery

Hunger, bowel sounds, passage of flatus, minimal abdominal distention

Monitor and document food and fluid intake

Weigh patient daily
Maintain total parenteral nutrition(TPN) and central IV lines as
ordered
TPN prevents tissue catabolism and promotes healing

Nursing Process: Implementation

Anticipatory Grieving
Work to develop a trusting relationship with the client and
family
Listen actively, encouraging expression of fears and concerns
Demonstrate respect for cultural, spiritual, and religious values and
beliefs
Encourage discussion of potential impact of loss on family members
Refer to cancer support groups, social services, counseling

Nursing Process: Evaluation

Risk for Sexual Dysfunction
Provide opportunities for the patient and family to express
feelings about diagnosis, ostomy
Provide consistent colostomy care
Encourage expression of sexual concerns
Reassure that the effect of physical illness and interventions
on sexuality usually is temporary
Refer patient and significant other to social services or
counseling
Arrange for a visit from a member of the United Ostomy
Association, if available

Case Study
G.O. is a 65-year-old man who is admitted for a colon
resection following a diagnosis of colorectal cancer.
At time of admission, he complains of constipation, bloody
stools, abdominal pain, and weight loss.
He is 6 feet 1 inch tall and weighs 200 lb.
He smokes 1 pack of cigarettes/day.
Has a history of coronary artery disease and hypertension.
Reports taking antihypertensive medication and 81 mg of
aspirin daily.
G.O. wants to know how he got colon cancer. What risk factors
does he have?

Case Study
G.O. is going to have abdominal surgery for his stage I
tumor.
What is the priority care before surgery?

G.O. is very upset.

He has many questions about his diagnosis and upcoming
surgery.
What interventions are appropriate to help alleviate his stress?
What does G.O. need to know about how smoking can affect
his health?
What should you teach G.O.s wife and family in regard to his
postoperative health care needs?
What follow-up care will G.O. need once he has healed from

Exemplar: Breast Cancer

Breast Cancer
The most common cancer in women
The most common cause of death from cancer among
Hispanic women.
The second most common cause of death from cancer among
white, black, Asian/Pacific Islander, and American
Indian/Alaska Native women.
In 2011 (the most recent year numbers are available)
220,097 women and 2,078 men in the United States were
diagnosed with breast cancer.
40,931 women and 443 men in the United States died from breast
cancer.

Breast Cancer: Pathophysiology

Classified as noninvasive or invasive
May remain in the same state without metastasis for long
period of time
May be categorized as :
Carcinoma of mammary ducts
Carcinoma of mammary lobules
Sarcoma of the breast

Many histologic types of breast cancer

Most common is infiltrating ductal carcinoma
Atypical types: inflammatory carcinoma and Pagets disease

Breast Cancer: Etiology

Five percent to 10% are hereditary
Genetic link stronger if the involved family member

Has a history of ovarian cancer

Is premenopausal
Had bilateral breast cancer
Is a first-degree relative
Breast cancer risk is by 1.5 to 3 times

Breast Cancer: Risk Factors

Nonmodifiable

Family history
Environmental factors
Genetics
Early menarche and late
menopause
Age 60 or older

Modifiable

Excess weight gain during

adulthood
Sedentary life style
Smoking
Dietary fat intake
Obesity
Alcohol intake
Environmental factors
Radiation exposure

Breast Cancer: Gerontologic

Considerations
Major risk for breast cancer is increasing age
More than half of all breast cancers are diagnosed in women
aged 65 or older
Older women are less likely to have mammography
Screening and treatment decisions are based on health status
and not age

Breast Cancer: Men

Risk Factors for Men:
Hyperestrogenism
Family history of breast cancer
Radiation exposure
Thorough breast examination with physical examinations
Possible genetic testing for men in families with BRCA mutations
Screening for risk of prostate cancer

Breast Cancer
Classification
Breast cancer can be classified as
Ductal carcinoma
Epithelial lining of the ducts

Lobular carcinoma
Epithelium of the lobules

Noninvasive or in situ cancer

Arises within the duct

Invasive cancer
Invades through the wall of the duct

Breast Cancer
Metastatic breast cancer
Most commonly spreads to the bones (primarily), liver, lungs,
and brain
Factors that affect prognosis

Tumor size
Axillary node involvement
Tumor differentiation
Estrogen and progesterone receptor status
Human epidermal growth factor receptors

Breast Cancer: Inflammatory Breast

Cancer
Aggressive and fast growing
High risk for metastasis
Lymph channels in skin of the breast become blocked by
cancer cells
Breast looks red, feels warm
Breast skin has a thickened appearance, resembling an
orange peel

Breast Cancer: Clinical

Manifestations
Detected as lump, thickening, or mammographic
abnormality in breast
Most often in upper-outer quadrant of breast
Dense with glandular tissue

Rate of lesion growth varies

Slow-growing lesions associated with lower mortality rates

Breast Cancer: Complications

Recurrence
Metastases
Local: skin
Regional: lymph nodes
Distant: bones, spinal cord, brain, lungs, liver, bone marrow
Metastatic disease can be found at any distant site

Breast Cancer: Collaborative Care

All options should be considered and discussed

Surgical intervention
Radiation therapy
Chemotherapy
Hormonal therapy
Biologic therapy

Breast Cancer
Collaborative Care: Diagnosis
Clinical breast exam
Mammography
Breast biopsy
Aspiration biopsy
Excisional biopsy

Breast Cancer
Collaborative Care: Surgery
Most common surgical
procedures for breast
cancer
Lumpectomy
Breast conservation surgery

Modified radical
mastectomy
Patients with early-stage
breast cancer are
candidates for either
treatment choice
Tumors smaller than 4 to 5
cm

Collaborative Care:
Breast-Conserving Therapy
Lumpectomy (partial mastectomy)
Involves removal of entire tumor with a margin of normal tissue

Radiation therapy after surgery

Delivered to entire breast, ending with a boost to tumor bed

Chemotherapy before radiation therapy

For evidence of high recurrence risk

Contraindications include

Size of breast in relation to size of tumor

Masses and calcifications that are multifocal in same breast quadrant
Masses that are multicentric or located in more than one quadrant
Diffuse calcifications in more than one quadrant

Collaborative Care: Surgery

Axillary Node Dissection
Axillary lymph node dissection
Performed with lumpectomy on same side as breast cancer
Typical ALND involves removing
12 to 20 nodes
Reserved for patients with evidence of disease in the axilla

Collaborative Care: Surgery

Axillary Node Dissection
Lymphedema
Accumulation of lymph in soft tissues
Possible after excision or irradiation of lymph nodes
Axillary nodes cannot return lymph fluid to central circulation
Fluid accumulates in arm
Causes obstructive pressure on veins and venous return

Collaborative Care: Surgery

Modified Radical Mastectomy
Removal of breast and axillary lymph nodes
Preserves pectoralis major muscle

Selected instead of breast-conserving surgery if tumor

is too large to excise
Breast reconstruction can follow

Collaborative Care: Surgery

Post-mastectomy Pain Syndrome
Can occur following a mastectomy or an axillary node dissection
Persistent symptoms
Chest and upper arm pain, tingling down arm
Numbness; shooting or prickling pain
Unbearable itching

Treatment includes

Nonsteroidal antiinflammatory drugs

Antidepressants
Topical lidocaine patches or EMLA
Antiseizure drugs

Follow-Up and Survivorship Care

Ongoing survivorship care
Follow-up examinations every 3 to 6 months for the first 5
years and annually thereafter
Care plans to identify surveillance strategies
Monthly BSE
Self-chest wall examinations
Reporting changes to health care provide

Nursing Process: Assessment

History of breast disorder assists in establishing
diagnoses
Presence of nipple discharge
Color, consistency, from one or both breasts

Pain
Rate of growth of lump
Breast asymmetry
Correlation with menstrual cycle
Health history

Nursing Process: Plan

The client will express feelings regarding diagnosis,
treatment, and prognosis.
The client will not experience infection.
The client will make informed treatment decisions.
The family and significant others will provide
appropriate support for the client.

Nursing Process: Acute Intervention

Waiting for biopsy results and treatment
recommendations are difficult periods of time
Woman often relies on you to clarify and expand on
options
Be aware of coping difficulties

Explore usual decision-making processes

Help evaluate advantages and disadvantages of options
Provide relevant information
Clarify unresolved issues with the health care provider
Support patient and family choices

Nursing Process: Acute Intervention

Postoperative discomfort can be minimized with
analgesics
Regularly when the patient has pain
Approximately 30 minutes before exercise

When showering is appropriate, warm water has a

soothing effect and decreases joint stiffness

Nursing Process: Implementation

Anxiety
Provide opportunities to express thoughts and feelings.
Discuss with the woman her knowledge of breast cancer
Encourage discussion relating to immediate concerns about
resuming life activities.
Explain the surgical procedure.
Explain that it is normal to have decreased sensation in the
surgical area.

Nursing Process: Implementation

Decisional Conflict
Provide an opportunity for the woman to ask questions.
Focus on immediate concerns, provide current written
material.
Listen to the woman in a nonjudgmental manner during her
decision making process.
Provide opportunities, if possible, to meet others who have
had breast cancer surgery.
Facilitate a team approach with other health professions.

Nursing Process: Implementation

Grief
Listen attentively to expressions of grief, and watch for
nonverbal cues
Allow time to interact, and do not rush interactions.
Explain that it is normal to have periods of depression, anger,
and denial .
Involve the partner in helping the woman cope with her loss.

Nursing Process: Implementation

Risk for Infection
Assess the surgical dressings for bleeding, drainage, color,
and odor.
Observe the incision and IV sites for pain, redness, swelling,
drainage.
Change dressings and IV tubing using aseptic technique.
Encourage a protein-rich diet.
Teach the woman how to care for the drainage system, if
present.
At discharge, teach to watch for and report manifestations of
infection.
Explain skin manifestations after radiation therapy.

Nursing Process: Implementation

Disturbed Body Image
Assess how the woman views her body.
Explain that redness and swelling in the scar will fade with
time.
Include partner and family if possible when discussing plan of
care.
Offer pamphlets and suggest books/videos that might increase
knowledge.
Encourage woman to look at her incision when she feels ready.
If interested in breast reconstruction, provide written material
and encourage her to discuss with her physician.

Nursing Process: Implementation

Risk for Injury
Use nonsurgical side of body for BPs and IVs
Encourage range of motion exercises
Explain lymphedema massage and elastic compression bandage may help
control swelling
Place patient in semi-Fowlers position with affected arm elevated on a pillow
Flexing and extending fingers should begin in recovery room
Progressive increase in activity should be encouraged

Postoperative arm and shoulder exercises are instituted gradually at surgeons

direction
Exercises are designed to prevent contractures and muscle shortening,
maintain muscle tone
Improve lymph and blood circulation

Breast Cancer: Culturally Competent

Care
Incidence, mortality rates, and care issues vary among
diverse ethnic groups
Gender roles, health beliefs, religion, family structure
Dietary factors
Access and use of clinical breast examinations and screening
mammography

Breast Cancer: Mammoplasty

Surgical change in size or
shape of the breast
Elective surgery for
cosmetic purposes
Breast reconstruction after
mastectomy
Consider
Body image
Cultural values placed on the
breast
Outcomes and complications

Breast reconstruction

Achieve symmetry
Restore or preserve body
image
Timing should be based on
individual physical and
psychological needs
Immediate or delayed

Can restore contour of the

breast
Cannot restore lactation,
nipple sensation, or erectility

Breast Cancer: Breast Implants and

Tissue Expansion
Most common reconstruction technique currently used
Expander is placed under the pectoralis muscle
Gradually filled by weekly injections
May become the permanent implant or may have to be
replaced by one
Does not work well when extensive scar tissue is present

Breast Cancer: Tissue Flap

Procedures
Use of autologous tissue to re-create a breast mound
Muscle taken from several locations
Back: latissimus dorsi
Leaves additional scarring on the back

Abdomen: transverse rectus abdominis

Abdominoplasty-type effects on abdomen

Breast Cancer: Tissue Flap

Procedures
DIEP flap
Deep inferior epigastric artery perforator flap does not involve
use of muscle

Nipple-areolar reconstruction

More natural-appearing breast

Usually done several months after breast reconstruction
Tissue is taken from the breast area to create a new nipple
Tissue is taken from the labia, groin, or lower abdomen to
create an areola
Tattooing with permanent dye may be used

Breast Cancer: Home Care

Explain follow-up routine
Emphasize importance of ongoing monitoring and self-care
Teach what symptoms should be reported to the health care
provider
Inform mastectomy patients
Special garment choices
Breast prosthesis

Address implications of cancer diagnosis and breast surgery on

Sexual identity
Body image
Interpersonal relationships

Case Study
During examination, a mass is palpated in the upper outer quadrant of M.J.s left breast.
Nodes in the axillary area are palpable.
Mammography and biopsy are ordered for M.J.
The needle biopsy confirms intraductal carcinoma.
Answer the following questions and submit.
What risk factors does M.J. have? Can any of them be modified?
What psychosocial aspects can you explore?
What treatment options are available for M.J. with her diagnosis of intraductal
carcinoma?
What are some of the factors that influence her prognosis?
What follow-up should M.J. be instructed to maintain?

Connecting the Concept

How could you adapt/utilize the preceding information
when caring for a child with leukemia?
A geriatric patient with a brain tumor?
How do you manage comorbidities, i.e. diabetes,
hypertension, heart failure, alcoholism?
What is the impact of growth and development on both
patient age ranges in diagnostic and treatment phases?