Ignatavicius: Medical-Surgical Nursing, 9th Edition

Chapter 21: Principles of Cancer Development

Key Points

The priority concept applied in this chapter is CELLULAR REGULATION.

The most important interrelated concept is IMMUNITY.

• Most common types of altered cell growth, such as moles or skin tags, are benign
(harmless) and do not require intervention.
• Malignant cell growth, or cancer, however, is serious and, without intervention, leads to
death.
• Cancer is a common health problem in the United States and Canada.
• Nearly 1.5 million people are newly diagnosed with cancer each year.
• Some types of cancers can be prevented and others have better cure rates if diagnosed
early.

PATHOPHYSIOLOGY
• Growth of cells and tissues is expected during infancy and childhood.
• Cells located in tissues where there is constant damage or wear continue to grow by
mitosis or cell division long after maturation is complete.
• Growth of cells is well controlled through CELLULAR REGULATION, ensuring that the right
number of cells is always present in any tissue or organ.
• Growth that causes tissue to increase in size by enlarging each cell is hypertrophy.
• Growth that causes tissue to increase in size by increasing the number of cells is
hyperplasia.
• Normal cells have a small nuclear-to-cytoplasmic ratio, have differentiated functions
special to that cell, have tight adherence to each other, are nonmigratory, and have
orderly and well-regulated growth. Orderly and well-regulated growth or CELLULAR
REGULATION is a very important feature of normal cells.
o They divide (undergo mitosis) for only two reasons: (1) to develop normal tissue
or (2) to replace lost or damaged normal tissue.
• Rapid and continuous cell division is a normal feature of embryonic cells, which spend
most of their time within the cell cycle, actively reproducing.
• Apoptosis is programmed cell death. Not only do normal cells have to divide only when
needed and perform their specific differentiated functions, to ensure optimum body
function, but some cells also have to die at the appropriate time.

CANCER DEVELOPMENT
• Cancer cells originate from normal body cells that are capable of cell division.
• Transformation of a normal cell into a cancer cell involves mutation of the genes (DNA)
of the normal cell and indicates a problem with CELLULAR REGULATION.
• Oncogenes are not abnormal genes but are part of every cell’s normal makeup. When
overexpressed can cause a cell to develop into a tumor.

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Key Points 21-2

• The process of changing a normal cell into a cancer cell is called malignant
transformation.
o Only one cell has to undergo malignant transformation for cancer to begin.
• Benign tumors grow by expansion, whereas malignant tumors grow by invasion.
• Most tumors arise from cells that are capable of cell division.
• A key feature of cancer cells is the loss of apoptosis. These cells have an “infinite” life
span.
• Benign tumor cells are normal cells growing in the wrong place or at the wrong time,
such as moles or nasal polyps.
• Malignant cells are abnormal, serve no useful function, and are harmful to normal body
tissues.
• Cancer cells have the following features:
o Rapid or continuous cell division
o Loss of the specific appearance of their parent cells or anaplasia
o Large nuclear-to-cytoplasmic ratio
o Loss of specific functions
o Loose adherence, which leads to migration or metastasis
o Metastasis is a key feature of cancer cells and a major cause of death.
• Abnormal chromosomes or aneuploidy are common in cancer cells as they become more
malignant.
• Anaplasia is the cancer cells’ loss of the specific appearance of their parent cells.
• Carcinogenesis and oncogenesis are other names for cancer development.
• Rapid or continuous cell division occurs in many types of cancer cells because they re-
enter the cell cycle for mitosis almost continuously because CELLULAR REGULATION is
lost.
• The original tumor is called the primary tumor and is identified by the tissue from which
it arose, such as in breast cancer or lung cancer.
• Metastasis occurs when cancer cells move from the primary location by breaking off
from the original group and establishing remote colonies called metastatic or secondary
tumors.
o Tumors that metastasize from the primary site into another organ are still
designated as tumors of the originating tissue.
o Spread to distant organs and tissues requires cancer cells to penetrate blood
vessels, called bloodborne metastasis.
o Another way cancers metastasize is by lymphatic spread.
• Cancers are classified by the type of tissue from which they arise, such as connective
tissue tumors.
o Other ways to classify cancer include biologic behavior, anatomic site, and degree
of differentiation.
• Systems of grading and staging have been developed to help standardize cancer
diagnosis, prognosis, and treatment.
o Grading of a tumor classifies cellular aspects of the cancer.
o Grading also allows health care professionals to evaluate the results of
management and compare local, regional, national, and international statistics.
• Ploidy classifies tumor chromosomes as normal or abnormal.

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Key Points 21-3

• Staging classifies clinical aspects of the cancer.

o The American Joint Committee on Cancer developed the tumor, node,
metastasis (TNM) system to describe the general anatomic extent of cancers.
o The stages guide treatment and are useful for prognosis and comparison of
treatment results.
o TNM staging is not useful for leukemias or lymphomas.
o Additional specific staging systems include Dukes’ staging of colon and rectal
cancer and Clark’s levels method of staging skin cancer.
• Carcinogenesis takes years and depends on several tumor and patient factors.
• The three interacting factors that influence cancer development are exposure to
carcinogens, genetic predisposition, and immune function, accounting for variation from
one person to another.
• External factors, including environmental exposure, are responsible for about 80% of
cancer in North America.
• Personal factors, including IMMUNITY age as IMMUNITY is reduced, and genetic risk, also
affect whether a person is likely to develop cancer.
• Cancer incidence increases among patients Adults older than 60 years have reduced
immunity and a higher incidence of cancer compared with that of the general population
• Genetic risk for cancer occurs in a small percentage of the population; however, people
who have a genetic predisposition are at very high risk for cancer development.
o Patterns of genetic risk for cancer have also been identified, including inherited
predisposition, inherited conditions associated with cancer, and familial
clustering.
• An emerging issue in this area is that studies of chemoprevention performed using animal
models do not always correlate to a reduction of carcinogenesis in humans.
• In addition, there is person-to-person variability in human response to chemoprevention.
• It is likely that individual genetic factors influence the effectiveness of any agent in the
prevention of carcinogenesis.

CANCER PREVENTION
• Cancer prevention activities can focus on primary prevention or secondary prevention.
• Primary prevention is the use of strategies to prevent the actual occurrence of cancer,
most effective when there is a known cause for a cancer type.
• Secondary prevention is the use of screening strategies to detect cancer early, at a time
when cure or control is more likely.
• Tobacco use is a causative factor in 30% of all cancers.
o Inform all patients who smoke that smoking increases the risk for development of
many cancer types.
o Assist anyone interested in smoking cessation to find an appropriate smoking
cessation program.
• Teach patients to avoid smoking, to avoid excessive intake of animal fat, nitrites, and red
meat and limit alcohol consumption.
• Dietary recommendations include eating more bran, cruciferous vegetables, and foods
high in vitamin A and vitamin C.
• Teach patients to use sunscreen and to wear protective clothing during sun exposure.

Copyright © 2018 Elsevier Inc. All rights reserved.

Key Points 21-4

• Vaccination is a new method of primary cancer prevention. Gardasil and Cervarix are
vaccines for preventing infection from several forms of the human papillomavirus (HPV).
It is hoped that more vaccines will be developed for prevention of other types of cancers.
• Encourage patients to participate in the recommended cancer screening activities for their
age group and cancer risk category.
• Obtain a detailed family history (at least three generations) and use this information to
create a pedigree to assess the patient’s risk for familial or inherited cancer.
• Assess the patient’s knowledge about causes of cancer and his or her
screening/prevention practices.
• Assist patients who fear a cancer diagnosis to understand that finding cancer at an early
stage increases the chances for cure.
• Ask all patients about their exposures to environmental agents that are known or
suspected to increase the risk for cancer.
• Teach everyone, especially older adults, the seven warning signs of cancer:
o CAUTION
 Change in bowel or bladder habits
 A sore that does not heal
 Unusual bleeding or discharge
 Thickening or lump in the breast, testicles, or elsewhere
 Indigestion or difficulty swallowing
 Obvious change in the size, color, shape, or thickness of a wart, mole, or
mouth sore
 Nagging cough or hoarseness
• Teach people who are exposed to asbestos (or any other carcinogen) in the workplace to
use personal protective equipment that reduces direct contact with this substance.

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