CHAPTER 8

ONCOLOGY/HEMATOLOGY
Written by: Dr. Zeeshan Hoodbhoy, M.D. and Samiyah Hoodbhoy, PA-C

Cancer
A growth of uncontrolled cells

Types of Cancer
Solid Tumors
Associated with organs that they develop in
Ex: Lungs, Breast, Colon, Cervix
Hematological Cancers
Originate in the blood
Ex: Leukemia, Lymphoma, Multiple Myeloma

Definitions to Know:
Neoplasm
Abnormal growth of cells (AKA Tumor)
*This does not mean you have Cancer!*
Neoplastic diseases are conditions that cause tumor
growth BOTH benign and malignant
Malignant = Cancerous
Benign = Non Cancerous

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Metastasis
Cancer spreads and grows away from the primary site

Lymphatic System
Network/Route of vessels through which LYMPH
drains from the tissues into blood

Lymph
Colorless Fluid that contains WBC
WBC = Infection Fighters
Drains through Lymphatic System

Oncovirus
Virus that CAN cause Cancer (not always)
Ex: Hep B, HPV

Hematopoiesis
Formation of blood cellular components

Metastasis Routes
Local Seeding: Local Area of Primary Tumor
Blood Borne: MC in the blood
Lymphatic: Tumor near various lymphatic sites (early
Metastasis

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More Definitions to Know:
Anti-Neoplastic
Against Tumor
Oncology Medications
Treat CANCER
Hematology Medications
Treat diseases related to the BLOOD and blood
forming organs
CSF (Colony Stimulating Factors)
Induces rapid bone marrow recovery after
suppression by chemotherapy
Phlebitis (can be caused by Chemotherapy)
Inflammation of vein
Extravasation (can be caused by Chemotherapy)
Leakage/Infiltration of drug into tissue that surrounds
vein
Vessicant (can be caused by Chemotherapy)
Agent that causes blistering

What are the causes of Cancer

Carcinogens
UV
Radiation
H Pylori
Obesity
Genetics
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Age
Immunosuppressed People
Ex: HIV, Organ Transplants = Higher Risk

Early Detection Tests

Mammogram → Breast
40-55 years
Yearly

Pap Test → Ovarian/Uterine

Start at 21-29 years of age
Every 3 years
30-59 years of age
Every 5 years
> 65
Not needed

Testicular Self Exam

15-35 Years Old
Monthly
Colonoscopy/Sigmoidoscopy → Colon

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Warning Signs of Cancer → CAUTION

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Diagnostic Tests
Biopsy
*definitive means of diagnosis*
Surgical incision to get tissue and observe under
microscope
Needle → aspirate cells
Incisional → wedge shape from larger mass
Excisional → Complete Removal
Staging → Multiple needle/incisional biopsies where
spread is suspected

Assessment of Patient
Head to toe
Changes since last visit
Urine
Loss of weight
Bleeding (fatigue, platelets, stool, etc)
<50k platelets (concerning)
<20k platelets (infusion)
Internal Hemorrhage (ASK GRAPH)
Avoid contact sports
Avoid injections
Do not blow nose
*Anemia Education*
Iron Rich Foods
Meats
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 Shellfish
Eggs
Green Leafy Vegetables
Brown Rice
No coffee/tea (deters absorption)
Take with Vitamin C (enhances absorption)
Patients with diet low in Iron → vegans/vegetarians/
low protein diets
Increase iron requirement
Iron is not being absorbed
Malabsorption Syndrome
Blood loss
Menstruation
Hemorrhoids
Ulcers

White Blood Cells

Infection Fighters
NADIR
Lowest WBC Part
Ex: 10 days after
Chemotherapy = lowest WBC = NADIR

Treatment for NADIR (COLONY STIMULATING

FACTOR)
Given during or a couple of days after treatment
Filgastrim
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 Pegfilgastrim
Neupogen
Neulasta
Goal of these injections is to increase neutrophils/
WBC
Precautions
Mask
Hand Hygiene
Oral Hygiene
No Alcohol
Soft Bristle Toothbrush
Avoid Fresh Flowers
Avoid Large Crowds
No Live Vaccines (patient and people living with
them)
Avoid Invasive Procedures (rectal, catheter, etc.)

Anemia
Condition in which the blood doesn't have enough healthy
red blood cells

Anemia Treatment
Iron deficiency anemia
Treatment: IV/PO Iron

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Folate deficiency anemia
Treatment: PO folate

Vitamin B12 anemia

Treatment: PO/IM B12

Anemia of Chronic Disease:

Treatment: PO/IV Iron, erythropoietin GF, Leukopoiteic GF,
Thrombopoietic GF (RBCs, WBCs Platelets— give what
they don’t have and need!)

Acute blood loss anemia:

Treatment: blood transfusion, PRBC, platelets, FFPlasma

***AVOID ADMINISTERING CALCIUM SUPPLEMENTS/

ANTACIDS +/- 1 HOUR OF
FERROUS SULFATE BECAUSE IT DECREASES IRON
ABSORPTION***

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 Sickle Cell Anemia

Inherited
Autosomal Recessive
Both parents need to have it
Baby will have a 25% of getting it
African Americans- most common population
1 in 12 people will have this disease

What is the normal shape of and RBC?

Round-concave

Life span of RBC = 120 days

Life span of Sickle Cell= 20 days
This happens d/t abnormal hemoglobin

Sickle Cell Crisis

Sickle Cell Crisis beginning at 6-8months

Why?
These infants still have the fetal hemoglobin from their
mother which is protecting them and we then will see a
change in the hemoglobin during 6-8 months

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Patients should be roomed in a private room or semi-
private room with a patient who has a non-infectious
condition

Signs of a Sickle Cell Crisis

Grimacing
Grunting
Crying
Irritable
Swelling in the joints

Treatment
IVF
Pain meds
O2
Elevating the limbs
Rest
Respiratory checks
Blood transfusions

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Breast Cancer

2 Types of Breast Cancer

Invasive → Penetrates tissue
surrounding mammary ducts
(spreads around area where it
started)
Ductal → Stays in the duct

Common areas for Breast Cancer to

metastasize
Lungs
Liver
Bones
Brain

Diagnostic Tests
Self Breast Exam
7 days after onset of
menstruation
Use 3 fingers (index, middle,
third finger)
Do it in shower
Arm lifted up

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Biopsy → Definitive Diagnosis
Needle Aspiration
Surgical Removal

Risk Factors
Age
Family History
Early Menses
Late Menarche
Previous Ovarian/Breast/Uterine Cancer
Nulliparity
Late First Birth
Obesity
High Dose Radiation to Chest

Assessment / Signs & Symptoms

Self breast exam
Mammogram findings
Nipple Discharge
Nipple Retraction
Skin Dimpling
Lymphedema of affected arm
Skin Edema
Peau D’ Orange Skin
Asymmetrical breast more
than normal

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Treatment
Non-Surgical
Chemotherapy
Radiation
Medication

Surgical
Lumpectomy
Take out tumor and lymph node dissection
Simple Mastectomy
Take out breast tissue and nipple - lymph
nodes remain
Modified Radical Mastectomy
Take out breast tissue, nipples, and lymph
nodes. Muscles remain.
Post-Op Interventions
AASH
Semi-Fowlers
Monitor Vital Signs
Promote Deep Breaths
Monitor Drainage
Maintain Fluid/Electrolyte Balance
Massage Arm
No Injections on affected side
Isometric Exercises
Compression Sleeve

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 Look for swelling, infection, color changes on
operative side

Monitoring a Patient receiving Chemotherapy

Monitor WBC, CBC, Platelets, Uric Acid, Electrolytes
Monitor Bleeding: Petechia, Ecchymosis, Gums/Nose
Avoid IM injections/venipuncture
Monitor for fever, sore throat, infection
Loss of appetite
Bitter taste with medications
Make sure they are not losing weight
Antiemetics several hours before chemo and 12-48
hours post chemo
Hydration/IVF before, during, after treatment
Need 2-3 liters intake per day to maintain renal
function
Rapid destruction of cells = release URIC ACID
Allopurinol may be given prophylactically to lower
serum uric acid levels

Side Effects of Chemotherapy

Alopecia
Education:
Give patient support about wigs
Patient may want to match hair before they lose it
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 Nausea/Vomiting
Antiemetics
Diarrhea
Education:
Avoid spicy, fiber, warm foods
Warm food increase peristalsis
Infertility *IRREVERSIBLE*
Education:
Freezing eggs ($$$$)
Sperm banks
Counseling
Weakness
Weight Loss
Mucositis
Dry Skin
Ulcers

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 Mouth Sores
Assess for peripheral neuropathy

Safety/Care in Chemotherapy
PPE
Radiation gowns
Chemo spill kit
Pregnant = NO CHEMO HANDLING
Give as prescribed
Monitor for Phlebitis
Avoid Large Crowds
Avoid Live Vaccines
Monitor for Extravasation

Types of Medication
Chemotherapy
Radiation
Immunotherapy
Stimulates immune system to recognize cancer
cells and take actions to destroy/eliminate them
Colony Stimulating Factors (CSF)
Increase neutrophils
Interleukins
Interferons
Anti-neoplastic Medications
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Before Each Medication Encounter
Dose is based on body surface area and type of
cancer

Purpose of Medication
Increase survival time
Decrease complications
Enhance life/Cure

Medications Mechanisms
Interleukin
Helps immune system cells to recognize and destroy
abnormal body cells
Interferon
Think “interfere”
Slow tumor down
Stimulates proliferation
Target Therapy
Target cellular elements of cancer cells
Works at gene level
Be aware of ALLERGIES!

Cell Cycle Specific Medications

Anti-Metabolic Agent
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 Stop division of rapidly dividing cells
Side Effects
Dizziness
Weak
Ataxia
Photosensitivity
Stomatitis
Diarrhea
Interventions
Monitor renal function
Cerebella Function
Photosensitivity
Protective Clothing

Types of Anti-Metabolic Agents to be Familiar With

Cyarabine
S/E: Alopecia, stomatitis, hyperuricemia
Florouracil
S/E: Alopecia, Stomatitis,Diarrhea
*Photo toxic reactions (very sensitive to the sun,
skin can really start to peel on hands and feet
very heavily)
Cerebellar dysfunction; confusion, dizziness
Mercaptopurine
S/E: Hepatotoxicity, hyperuricemia
MTX

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 S/E: Alopecia, stomatitis, hyperuricemia,
photosensitivity, hepatotoxicity
Leukovorin
Given if too large of a dose of MTX is given to
prevent toxicity

Mitotic Inhibitors
Inhibiting Mitosis- goal is stop cell division
Cell Death
Side Effects
Anorexia
Leukopenia
Hoarseness
Motor Instability
Peripheral Neuropathy
Phlebitis
Hyperuricemia
Types
Remember “VIN Sisters” (this has appeared on boards!)
Cause peripheral neuropathy
Decrease of achilles tendon reflex
Vinorelbine
Vinca Alkaloids
Vincristine
Others to Know:
Docetaxel
Paclitaxel
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Topoisomerase Inhibitors
Block enzyme needed for DNA synthesis and cell
division
Medication: Etoposide

YOU WOULD GIVE SLOWLY OVER 30-60 MINUTES TO

AVOID HYPOTENSION/MONITOR BP

“TOP” DRUGS - ETOPOSIDE= think Orthostatic

HYPOtension and give SLOWLY!

Side effects
Anorexia
Alopecia
Orthostatic Hypotension
Hypersensitivity Reaction

Cell cycle NON-specific Medications

Alkylating agents
Antitumor Ab
Hormonal therapy

Alkylating agents
Break DNA helix and interfere with DNA replication during
the cell cycle

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Side Effects
Nausea
Vomiting
Anorexia
Stomatitis

Education things needed for this medication:

NEED PFTs- make sure the lungs are doing ok
Chest X-ray
Kidney/liver function
*Diet low in purines - to alkalinize urine and lower blood
levels/Uric acid

Types
Nitrogen mustards
Chlorambucil
Methlorethamine
Ifosfamide
Cyclophosphamide- *If taken orally, do not take with food*
Side Effect: hemorrhagic cystitis (blood in urine, irritation)

Ways to prevent to this?

Patient to drink 2-3 L/day of water unless c/i

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Bulsulfan = causes HYPERURICEMIA

WHAT LABS TO MONITOR IF ON THIS MEDICATION?

URIC ACID labs

Cisplatin Compounds
Commonly used chemo agent

Side Effects:
Ototoxicity
Tinnitus
Hypokalemia
Hypocalcemia
HypoMg
*nephrotoxicity

*CHECK URINE OUTPUT - have patients take a urine test

to check for NEPHROTOXICITY*

Patients who are on Cisplatin, what types of questions

do we want to ask them?
Any ringing of the ears? (tinnitus)
Do you feel dizzy?
Any hearing loss?

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Any urinary issues/urgency/pain?
Numbness/tingling

Antitumor Ab
MOA: Interfere with DNA/RNA synthesis

Side Effects:
Nausea
Vomiting
Fever
Rash
Stomatitis
Bone marrow depression
Gonadal suppression
Hyperuricemia

Daunorubicin
Doxorubicin
Idarubicin

*Remember, Rubicin cousins*

*These medications cause heart issues/problems*

Daunorubicin

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May cause heart failure and dysarrythmia

Doxorubicin/Idarubicin
May cause cardiotoxicity, cardiomyopathy, EKG changes

Bleomycin
May cause PULMONARY TOXICITY

What diagnostic method is needed to be assessed?

PFTS- ensure our lungs are working properly

Hormonal Therapy
Suppresses immune system and blocks normal hormones
in hormone sensitive tumors

*Sex characteristic alterations*

Masculine effects in women

Chest/facial hair, menses stops
Gynecomastia in men
Breast swelling, hot flashes, weight gain-everyone will
have these side effects

Both can have the s/e of Hemorrhagic cystitis

How can we prevent this?
2-3 L of fluids daily

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Other side effects:
HypOuricemia,
Hypercholesterolemia
HTN
Edema
Electrolyte Imbalance

When on hormonal therapy, it can be very easy to develop

a Thromboembolic Disorder

If on hormonal therapy= HIGHER risk to develop clots

Want to monitor patients

Types of Hormonal Therapy Drugs

Tamoxifen:
common type of hormonal therapy
Anti-estrogen
*Used commonly in breast cancer patients

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Targeted Therapy Drugs
targets cellular elements of cancer cells or antisense meds
that work at the gene level

Types:
Monoclonal Ab

Side Effects:
allergic, hypersensitivity reactions = lead to anaphylaxis
reactions

Anaphylaxis Reactions:
*Priority nursing action for Anaphylaxis*

1. Assess respiration status

2. Stop medicine
3. Contact PHCP/rapid response team
4. Administer O2
5. Maintain IV access with normal saline
6. Raise clines legs/feet IF NOT C.I.
7. Administer ER meds ex. Epinephrine
8. Monitor vitals
9. Document!

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Signs/symptoms of Anaphylaxis Reaction:
Dyspnea
Chest tightness/pain
Purities
Urticaria
Tachycardia
Dizziness
Anxiety/agitation
Flushed appearance
Hypotension
Decreased sensorium
Cyanosis
Interventions during an
Anaphylaxis Reaction
Stay with client during administration
Monitor vitals
Emergency equipment ready
Initiate IV access

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