According to the American Cancer Society, half of all men and one third of all women will develop cancer within their lifetime (Cancer. org). These figures are staggering. Cancer is a leading cause of morbidity and mortality worldwide and is a terrifying and unpredictable disease for many cancer sufferers. As such, it is imperative that healthcare workers have a thorough understanding of the various cancer diagnoses, treatments, and preventative strategies necessary to combat this devastating plague.
Skills at managing not only the illness itself, but also the psychological and social side effects that accompany treatment must also be at the forefront of effective care strategies. Diagnosing Cancer Because the term “cancer” encompasses a broad range of diseases, diagnosing this disease will vary according to the affected tissues or regions from which it originates. According to Webster’s, the definition of cancer is “a malignant tumor of potentially unlimited growth that expands locally by invasion and systemically by metastasis. It is this unlimited growth and the subsequent invasion of healthy tissue that makes cancers so deadly and aggressive treatment so vital. A suspected diagnosis of cancer generally begins with an examination of the presenting signs and symptoms. These symptoms will vary according to the type, location and extent of the cancer itself. Local symptoms of cancer are usually restricted to the primary site of the cancer. These symptoms may include new lumps or nodules, swelling, bruising or bleeding in or around the diseased tissue.
Metastatic symptoms may include enlarged lymph nodes, organomegaly (commonly seen in the liver and spleen) and bone pain and/or fractures. Systemic symptoms include weight loss, fatigue, sweating and anemia. While none of these symptoms is diagnostic, they are helpful in providing a starting point for a complete cancer workup. Lab tests for cancer may include tests for various tumor markers which are suggestive of neoplasms. Tumor markers are substances produced by cancer cells that are found either in or on the tumor cells or in the blood, spinal fluid, or urine (McCance 2010. For example, liver and germ cell tumors produce alpha fetoprotein (AFP) into the blood, and prostate tumors secrete prostate specific antigen (PSA) into the blood (McCance). A significant problem in diagnosing cancer using tumor marker assays, however, is that nonmalignant conditions can also produce tumor markers. Therefore, while the presence of such markers may suggest a neoplasm, they are not used in and of themselves to make a definitive diagnosis of cancer.
Whatever the initial complaints or lab tests show, once the diagnosis is suspected and a tumor has been identified, it is essential that tumor tissue be obtained to establish a definitive diagnosis and correctly classify the disease (McCance 2010). Various methods of tissue removal for examination include excisional, incisional and core biopsy, fine needle aspiration, and exfoliative cytology. The technique selected generally depends on the size, location, and type of tumor discovered, but regardless of the technique the goal is pathological examination under a microscope for the histological hallmarks of cancer.
These hallmarks of cancer cells include the loss of cellular differentiation, irregularities of the size and shape of the nucleus, and the loss of normal tissue structure (McCance 2010). Further classification of the cancer can be facilitated by tests such as immunohistological stains, flow cytometry, electron microscopy, chromosome analysis, and nucleic acid-based molecular studies (McCance 2010). Staging Once the diagnosis of cancer has been made, it is important that the cancer be staged in order to determine the extent to which it has spread. Cancer is generally staged in four parts.
Stage one is a cancer which is confined to the tissue of origin, stage two cancer is one that is invaded locally, stage three cancers have spread to regional structures such as the lymph nodes, and stage 4 cancers have spread distally to other tissues such as the lungs or bone. Knowing the stage of cancer is important in selecting appropriate treatment options and providing a prognosis. The prognosis is generally worse with increasing tumor size, lymph node involvement, and metastasis (McCance 2010). Complications of Cancer Complications arising from cancer are as diverse as the hundreds of different types of cancer itself.
Complications include paraneoplastic syndromes, pain, and infection. In addition to complications from the cancer itself, the treatments for cancer often have serious and sometimes deadly side effects as well. One aspect of what makes cancer treatment so challenging is that these complications and side effects of the cancer and its various therapies must be treated in addition to the underlying tumor itself. Paraneoplastic syndromes are symptom complexes that are triggered by a cancer but are not caused by direct local effects of the tumor mass (McCance 2010).
These symptoms are usually caused by hormones or other biological substances released by the tumor. Examples of paraneoplastic syndromes related to neoplasms include Cushing syndrome, polycythemia, and nephrotic syndrome, among many others. These symptoms, while rare, are important because they can precede other symptoms of cancer by several months (McCance 2010). Treatment for these syndromes are often undertaken independently of the cancer treatment as a separate illness, despite having a causal mechanism linked to the cancer. Pain is one of the most common and feared complications of cancer.
It is exacerbated by stress, anxiety, fatigue, and malaise which accompany advanced cancer. Pain is generally absent in the early stages of cancer, but it is a significant factor as the illness progresses to advanced stages. Cancer-associated pain can arise from a variety of direct and indirect mechanisms including direct pressure, obstruction, and invasion of a sensitive structure, stretching of visceral surfaces, tissue destruction, infection, and inflammation (McCance 2010). Pain is generally accepted as whatever the patient says it is, wherever the patient says it is.
Treatment of pain and its associated symptoms is a primary responsibility of the healthcare team. Treatment modalities for pain include the use of opioid analgesics, patient-controlled analgesia, psychological interventions, and preventing recurrence of pain. Reinforcing the reporting of pain by the patient is important, as is a respect for the social and cultural differences with respect to pain perception. Individuals with cancer are predisposed to infection and are at a greatly increased risk for death from infection-related illnesses.
In addition to the immunosuppressive effects of the cancer itself, individuals with cancer may be at increase risk for infection due to surgery and treatments such as chemotherapy and radiation. Frequent hospital stays and devices such as indwelling catheters and proximity to other potentially infectious patients increases the cancer patient’s risk of acquiring nosocomial infections as well. Treatment options Cancer treatments generally include surgery, radiation, chemotherapy and a combination of these modalities.
The therapeutic regimen is selected based on the type and extent of cancer present. The effectiveness of each therapy is dependent primarily on the stage of the cancer and the ability to prevent the systemic spread of the disease. The treatment options are not guaranteed to cure the illness, and nor are they without serious and debilitating side effects. In patients in whom a cancer has not spread beyond the limits of surgical excision, surgery is often the first line of defense against a malignant neoplasm.
In addition to providing samples for biopsy, effective surgery is often able to remove the entire tumor prior to metastasis if performed while the disease is in its early stages. It is often used in high-risk populations as a preventative measure as well. Surgical risks include risk for infection, ineffective tumor isolation and body image disturbances. Surgical treatment needs to be coupled with treatments that address these risks as well. Antibiotic therapy, counseling, and cosmetic concerns all need to be attended to in concert with any invasive surgical therapy.
Radiation therapy is used to destroy cancerous cells while minimizing damage to normal cells and surrounding tissues. In this treatment option, ionizing radiation damages cells by imparting enough energy to cause molecular damage, especially to DNA (McCance 2010). Radiation therapy decreases the size of tumors and in some cases may eradicate them. Radiation can be used to shrink tumors, allowing surgical removal that would otherwise not be possible. Because tumors and their metastases can cause pain, radiating those cancerous areas may significantly reduce pain.
Radiation therapy is often used for palliation and pain relief when other treatments are not possible or have not been successful (JAMA. org). Side effects of radiation therapy include: skin redness near the radiated site, fatigue, infertility, nausea, vomiting, hair loss, and diarrhea. In some cases, a second cancer can arise as a direct result of the therapy itself. Treatment of the side effects of radioactive therapy is selective to those effects experienced and may include antiemetics, counseling, and additional therapies such as surgery and chemotherapy.
Chemotherapy is a specialized area used in oncology that takes advantage of specific vulnerabilities in target cancer cells (McCance 2010). Chemotherapy is rarely given in single-drug treatments. While some chemotherapeutic agents may shrink cancer cells, it often takes a more aggressive approach, incorporating a cocktail of several drugs to eradicate a cancer. Most chemotherapeutic therapies involve attacking a cancer from many different areas of weakness. Because cancers contain a very large number of cells, many of these may be resistant to the first-line drug but will be susceptible to a second or third drug.
In addition, chemotherapy generally is done very aggressively because the more delay there is between various drug administrations, the more likely the cancer cells will be resistant to treatment. Side effects of chemotherapy are many and include: sexual dysfunction, nausea, vomiting, pain, anemia, memory loss, and a host of other maladies. Educating patients about the potential side effects and treating the symptoms as each arises and preventing them when possible is the key to coping with this powerful drug regimen.
Conclusion Cancer, while a terrifying diagnosis with an uncertain outcome, is not the death sentence that many people believe it to be. With proper treatment, education, and early detection, it can be successfully overcome in many instances. However, healthcare providers need to have an in depth understanding of what to expect when caring for patients if they are to anticipate and treat the physiological and psychological pains that accompany this disease.