1. Chapter 16 Cancer: Part 1 Biology, Classification, Diagnosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2. Cancer Group of more than 200 diseases Characterized by uncontrolled and unregulated growth of cells Occurs in people of all ages 77% of cases are diagnosed in those over age 55. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Cancer More than 1.6 million persons are expected to be diagnosed with invasive carcinoma in 2013. Excluding basal and squamous cell skin cancers Incidence has been declining since the 1990s. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

4. Cancer Mortality rates are declining. Incidences of lung, colorectal, breast, and oral cancer have ↓ Largely due to preventive efforts Other cancers have ↑ Leukemia, liver cancer, skin cancers Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5. Cancer Higher in men than women Second most common cause of death in the United States after heart disease Leading cause of death in people less than 85 years of age Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6. Cancer 5-Year survival rate is now 68% for those who are Disease free In remission Under treatment Does not include number of people who are “cured” of cancer Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

7. Biology of Cancer Two major dysfunctions in the process of cancer development: 1.Defective cell proliferation (growth) 2.Defective cell differentiation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8. Defective Cell Proliferation Stem cells Undifferentiated cells Ultimately differentiate and become mature, functioning cells of only that tissue Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9. Defect in Cellular Proliferation All cells are controlled by an intracellular mechanism that determines proliferation. Cancer cells grown in culture are characterized by loss of contact inhibition. Grow on top of one another and on top of or between normal cells Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10. Defect in Cellular Proliferation Cancer cells respond differently than normal cells to intracellular signals regulating equilibrium. Divide indiscriminately Divide haphazardly Can produce > 2 cells during mitosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

11. Defect in Cellular Proliferation Pyramid effect Exponential growth of cancer cells from continuous and indiscriminate proliferation 1 X 2 X 4 X 8 X 16 X 32……. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

12. Normal Cellular Differentiation Orderly process progressing from a state of immaturity to a state of maturity Stable and will not change Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13. Defect in Cellular Differentiation Tumor suppressor genes Function to regulate cell growth Prevent cells from going through the cell cycle Mutations make them inactive. Result in loss of suppression of tumor growth Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14. Process of Cancer Development Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15. Development of Cancer Initiation 1 st stage Mutation of cell’s genetic structure Any change in the usual DNA sequence Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16. Gene Mutations Inherited 5% of all cancers or the predisposition to the cancers are inherited. Lead to a very high risk for cancer Acquired Most cancers are acquired. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. Carcinogens Cancer-causing agents capable of producing cell alterations Many are detoxified by protective enzymes and are harmlessly excreted. Failure of protective mechanisms allows them to enter the cell’s nucleus and alter DNA. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18. Development of Cancer Carcinogens may be Chemical Radiation Viral Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19. Development of Cancer Chemical carcinogens Many chemicals have been identified as carcinogens over the years. Long latency period makes identification of carcinogens difficult. Certain drugs have been identified as carcinogens. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20. Development of Cancer Radiation Radiation can cause cancer in almost any human tissue. Damage occurs to the DNA. Ultraviolet radiation is associated with melanoma and squamous and basal cell carcinoma. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

21. Development of Cancer Viral carcinogens Copyright © 2014 by Mosby, an imprint of Elsevier Inc. VirusAssociated Cancer Epstein-Barr virus (EBV)Burkitt’s lymphoma Human immunodeficiency virus (HIV) Kaposi sarcoma Hepatitis B virus Hepatocellular carcinoma Human papillomavirus Squamous cell carcinomas

22. Development of Cancer Promotion Characterized by reversible proliferation of altered cells Activities of promotion are reversible. Obesity Smoking, alcohol Dietary fat Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

23. Development of Cancer Latent period May range from 1 to 40 years Length of latent period associated with mitotic rate of tissue of origin and environmental factors For disease to be clinically evident, tumor must reach a critical mass that can be detected. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

24. Development of Cancer Progression Characterized by Increased growth rate of tumor Invasiveness Metastasis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

25. Main Sites of Metastasis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

26. Pathogenesis of Cancer Metastasis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

27. Development of Cancer Progression Metastasis process begins with rapid growth of primary tumor. Develops its own blood supply Tumor angiogenesis Tumor cells can detach and invade surrounding tissues. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

28. Development of Cancer Progression Metastasis process Detached cells can invade lymph nodes and vascular vessels to travel to distant sites. Most mobile tumor cells do not survive. Surviving tumor cells must create an environment conducive to growth and development. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

29. Role of Immune System Immune response is to reject or destroy cancer cells. May be inadequate as cancer cells arise from normal human cells Some cancer cells have changes on their surface antigens. Tumor-associated antigens (TAAs) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

30. Tumor-Associated Antigens on Cell Surface Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

31. Role of Immune System Immunologic surveillance Response to TAAs Lymphocytes continually check cell surface antigens and detect and destroy abnormal cells. Involves cytotoxic T cells, natural killer cells, macrophages, and B cells Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

32. Role of Immune System Cytotoxic T cells Kill tumor cells directly Produce cytokines Natural killer cells and activated macrophages can lyse tumor cells. B cells produce antibodies that bind to tumor cells. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

33. Role of Immune System Immunologic escape Mechanism by which cancer cells evade immune system Suppression of factors that stimulate T cells Weak surface antigens allow cancer cells to “sneak through” surveillance. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

34. Role of Immune System Immunologic escape Develops tolerance to immune system by some tumor antigens Suppresses immune response from products secreted by cancer cells Induction of suppressor T cells Blocking antibodies bind TAAs, preventing recognition. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

35. Tumor Escape Mechanism Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

36. Benign vs. Malignant Neoplasms Tumors can be classified as benign or malignant. Ability of malignant tumor cells to invade and metastasize is the major difference between benign and malignant neoplasms. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

37. Classification of Cancer Tumors can be classified by Anatomic site Histology Grading severity Extent of disease Staging Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

38. Classification of Cancer Classification systems provide a standardized way to Communicate with health care team Prepare and evaluate treatment plan Determine prognosis Compare groups statistically. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

39. Classification of Cancer Anatomic site classification Identified by tissue of origin Carcinomas originate from Embryonal ectoderm (skin, glands) Endoderm (mucous membrane of respiratory tract, GI and GU tracts) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

40. Classification of Cancer Anatomic site classification Sarcomas originate from Embryonal mesoderm (connective tissue, muscle, bone, and fat) Lymphomas and leukemias originate from Hematopoietic system Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

41. Classification of Cancer Histologic classification Appearance of cells and degree of differentiation are evaluated to determine how closely cells resemble tissue of origin. Poorly differentiated tumors have a worse prognosis than those closer in appearance to normal cells. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

42. Classification of Cancer Four grades of abnormal cells Grade I Cells differ slightly from normal cells and are well differentiated. Grade II Cells are more abnormal and moderately differentiated. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

43. Classification of Cancer Four grades Grade III Cells are very abnormal and poorly differentiated. Grade IV Cells are immature and primitive and undifferentiated. Cell of origin is difficult to determine. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

44. Classification of Cancer Clinical staging classifications 0: Cancer in situ 1: Tumor limited to tissue of origin; localized tumor growth 2: Limited local spread 3: Extensive local and regional spread 4: Metastasis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

45. Classification of Cancer TNM classification system Anatomic extent of disease is based on three parameters: Tumor size and invasiveness (T) Spread to lymph nodes (N) Metastasis (M). Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

46. Diagnoses of Cancer Patient may experience fear and anxiety. You should Actively listen to patient’s concerns. Manage your own discomfort. Give clear explanations; repeat if necessary. Give written information for reinforcement. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

47. Diagnoses of Cancer Diagnostic plan includes Health history History of present illness Identification of risk factors Physical examination Specific diagnostic studies Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

48. Diagnoses of Cancer Indicated diagnostic studies depend on site of cancer Cytology studies Chest x-ray CBC, chemistry profile Liver function studies Endoscopic examinations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

49. Diagnoses of Cancer Indicated diagnostic studies depend on site of cancer Radiographic studies Radioisotope scans PET scan Tumor markers Genetic markers Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

50. PET scan Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

51. Diagnoses of Cancer Indicated diagnostic studies depend on site of cancer Molecular receptor status Bone marrow examination Biopsy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

52. Diagnoses of Cancer Biopsy involves histologic examination by a pathologist of a piece of tissue. Tissue may be obtained by Needle or aspiration Incisional procedure Excisional procedure. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

53. Prevention and Detection of Cancer Lifestyle habits to reduce risks: Practice recommended cancer screenings. Practice self-examination. Know seven warning signs of cancer. Seek medical care if cancer is suspected. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

54. Prevention and Detection of Cancer Lifestyle habits to reduce risks: Avoid or reduce exposure to known or suspected carcinogens: Cigarette smoke, excessive sun exposure Eat a balanced diet. Limit alcohol intake. Exercise regularly. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

55. Prevention and Detection of Cancer Lifestyle habits to reduce risks: Maintain a healthy weight. Get adequate rest. Eliminate, reduce, or cope with stress. Have a regular health examination. Be familiar with your family history. Know your risk factors. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

56. A nurse plans a community education program related to prevention of the cancer with the highest death rates in both women and men. What should the nurse include in the teaching plan? a.Smoking cessation b.Screening with colonoscopy c.Regular examination of reproductive organs d.Use of sunscreen as protection from ultraviolet light Audience Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc.