At the end of this module, the learner will be able to:
- Describe the pathophysiology of cancer and the basis for cancer diagnosis and staging.
- Describe the nurse’s role and scope of practice in the care of the cancer patient.
- Identify the nurse’s role in the early detection and prevention of cancer.
- Identify the types of surgical interventions for cancer and the nurse’s role in caring for surgical oncology patients.
- Identify the basic principles of radiation therapy, radiation safety, and nursing interventions for skin care associated with radiation therapy.
The purpose of this module is to provide an overview of the field of oncology nursing, outlining the cancer diagnosis and staging process, as well as the role, responsibilities, and professional performance of the surgical oncology and radiation oncology nurse.
Cancer is a cluster of malignant diseases characterized by abnormal cell growth, the ability to invade surrounding tissue and lymph nodes, and metastasize (spread) to distant locations within the body (Nettina, 2019). The definition of the term ‘cancer' has evolved over the last several decades as biological research has successfully enhanced the scientific understanding of cancer development and the methods in which cancers grow and spread (Yarbro, Wujcik, & Gobel, 2018). As treatment advancements and new drug developments have successfully contributed to improved quality and longevity of life, oncologic care has become increasingly complex, with nurses at the core of care delivery (Neuss et al., 2016). Innovative technology, combined with sophisticated treatment planning, has demanded that oncology nurses acquire and maintain comprehensive knowledge and high-level skill regarding cancer pathophysiology, treatment modalities, and symptom management. Oncology nurses fill diverse and specialized roles throughout the cancer trajectory, from cancer prevention and diagnosis, throughout cancer survivorship. While the oncology nurse's role continues to evolve alongside new scientific discoveries, the paramount purpose remains unchanged: grounded in the timely, effective, and safe delivery of evidence-based patient care (Yarbro et al., 2018).
According to the American Cancer Society (ACS, 2018a), more than 1.7 million new cancers are expected to be diagnosed in the United States in 2019, with approximately 606,880 cancer-related deaths; or nearly 1,660 deaths per day. Cancer is the second most common cause of death in the U.S.; exceeded only by heart disease. There are an estimated 16.9 million cancer survivors in the U.S., which represents 5% of the population, and is projected to increase to 26.1 million by 2040 (Bluethmann, Mariotto, & Rowland, 2016). The ACS cites age as the most outstanding risk factor for cancer development, given the aging baby boomer population, advancements in cancer treatment, and increased numbers of cancer survivors. Therefore, nurses with specialized oncologic education and training are at the height of current nursing demands (ACS, 2018a).
Pathophysiology of Cancer
Cancer cells have distinct features in comparison to healthy cells, such as the way they appear under a microscope, how they grow, replicate, and their overall function. When cancer cells collect in one area, they develop into a malignant (or cancerous) tumor. Normal, healthy cells reproduce in an organized, controlled, and orderly manner as they mature into individual cells that serve specific functions and have predetermined lifespans. They undergo apoptosis, or programmed cell death, which is the process in which the body rids itself of unneeded cells. They do not divide when space or nutrients are limited and do not spread to other parts of the body where they do not belong (Yarbro et al., 2018).
In contrast, cancer cells are less specialized, exhibit dysplasia (disorganized growth) and hyperplasia (increased size). They can evade apoptosis, as they continue to divide and grow uncontrollably, even when space is confined (Polovich, Olsen, & LeFebvre, 2014). Cancer cells initiate new growth at distant sites (metastasize) and manipulate healthy cells to generate blood vessels (angiogenesis) to supply the tumor with the additional oxygen and nutrients needed to grow. Given their duplicitous appearance, cancer cells can hide from and evade the immune system, preventing it from recognizing them as abnormal and eradicating them (Nettina, 2019). All cancer is inherently genetic, as cancer cells harvest genetic mutations that lead to uncontrolled cell division and growth; however, not all cancer is hereditary. Inherited (or hereditary) cancer occurs only when a damaged gene with a high susceptibility to cancer is passed down through generations within a family. In these cases, a patient with a hereditary cancer is born with a genetic mutation and genetic predisposition to develop cancer at some point in their lives (Ring & Modesitt, 2018). Metastases, the secondary growth of the primary cancer in another organ, occurs after a cancerous cell detaches from the original tumor site, invades local tissue, and migrates through the lymphatics and/or blood vessels to another area of the body. Over time, the cancerous cell replicates in the new area, creating a secondary tumor site (Nettina, 2019). The four most common sites that cancers metastasize include the liver, lung, bone, and central nervous system. A common misconception among patients with metastatic cancer is that they have developed a secondary cancer type, so vigilant patient and family education is often required to ensure accurate understanding (Yarbro et al., 2018).
The Role of the Oncology Nurse
The role of the oncology nurse has expanded significantly as the landscape of cancer care has progressed and continues to evolve in response to the changing needs of cancer patients and families. Oncology nursing is a highly demanding sector of nursing and healthcare; both physically and emotionally. Oncology nursing involves direct patient care and assessment, patient and family education, coordination of care, symptom management, and supportive care. Oncology nurses practice in various settings, including hospitals, outpatient infusion centers or clinics, private medical offices, radiation treatment facilities, and home healthcare agencies. Equally as broad as the environment is the scope of practice, responsibilities, and sub-specialization of the oncology nurse. Some nurses specialize in intensive care settings, involved in highly complex surgeries or care for patients undergoing bone marrow transplantations. Others administer chemotherapy in an office setting, whereas many work in the community, focusing on cancer screening, detection, and prevention. As treatments have become increasingly complex, so has the collaborative relationship between the nurse and the physician/provider team. Comprehensive, efficient, and safe oncologic care is primarily premised on the partnership and communication among team members. There has been a move toward transitioning the majority of cancer care to the outpatient settings, reserving inpatient care for surgical needs, those with higher-level acuity, and oncologic emergencies (Neuss et al., 2016).
Oncology nurses are tasked with complex responsibilities, such as managing both the symptoms of a patient's disease and the side effects of various cancer treatments. Therefore, nurses must ascertain a detailed and thorough understanding of the biology of cancer, cancer treatment, and all its implications. Nurses play an integral role in the administration of chemotherapy and other anti-cancer therapies, the responsible and safe handling of these hazardous medications, the evaluation of laboratory data, and the calculation of drug dosages to ensure accuracy. Nurses administering anti-cancer medications must be well-versed on treatment regimens, how the drugs work, the sequence in which they must be administered, as well as any potential adverse effects, such as allergic (hypersensitivity) reactions. Hypersensitivity reactions are oncologic emergencies, warranting immediate action to prevent morbidity, as these incidents can rapidly progress to life-threatening situations. Oncology nurses manage intravenous lines, including central venous devices, which require continuous and ongoing monitoring. They are often the first point of contact for patients calling with symptoms, side effects, and other concerns. Telephone triage is a critical skill that nurses working in outpatient clinics, offices, and community settings must acquire, as signs of infection in a cancer patient undergoing chemotherapy may be very vague due to immunosuppression. Therefore, the skill of the nurse triaging the call is critical to ensure the safety of the patient (Neuss et al., 2016).
The oncology nurse plays a significant role in educating patients about their disease, its treatments, and expected side effects. They must ascertain the level of understanding each patient and their families possess and would like to have, and then tailor education accordingly. Oncology nurses may be tasked with organizing relevant referrals for patients to other healthcare providers, such as dieticians, social workers, physical therapists, occupational therapists, or speech pathologists. As oncologic care becomes increasingly subspecialized, nurses acquire unique skill sets and knowledge within the specialty field in which they practice, such as breast cancer or lung cancer. Therefore, it is difficult to comprehensively define and capture all the roles and responsibilities of the oncology nurse given the uniqueness and the high variability among each position. What it means to be an oncology nurse also differs across various settings, cultures, experience, and individual identities as nurses. The scope of practice is further defined by and narrowed down by state laws and the nursing practice act (Olsen, LeFebvre & Brassil, 2019).
As part of its mission to promote excellence in oncology nursing, the Oncology Nursing Society (ONS), an accredited organization by the American Nurses Credential Center's Commission on Accreditation, developed core competencies for the oncology nurse generalist identifying the fundamental knowledge, skills, and expertise required for a novice oncology nurse to proficiently perform the role (ONS, 2016). Since the nurse is often the first and last healthcare professional to ensure that safety standards are implemented for patients with cancer, the development of standardized oncology nurse generalist competencies help safeguard patients and secure quality professional practice. The intent of the core competencies is to provide the fundamental knowledge, skills, and expertise required for oncology nurses to perform proficiently in their roles. The oncology nurse plays a critical role in the delivery of quality nursing care to a high-risk and complex patient population, as they serve as integral members of high-quality, interdisciplinary care teams. The ONS Oncology Nurse Generalist Competencies (2016) support the novice oncology nurse's successful transition into entry-level oncology practice and form a firm foundation for daily clinical practice, professional development, and career progression. The document outlines specific competencies within core areas of teamwork, professional development, evidence-based clinical care, financial, and quality (ONS, 2016).
The Nurse’s Role in Early Detection and Prevention of Cancer
While the definitive cause of cancer is not entirely understood, numerous factors are identified as increasing the risk for the disease and are generally distributed among two categories; modifiable and non-modifiable. Some theories postulate that cancer may occasionally occur due to the spontaneous transformation of the cell, where no causative agent is identified. Although this etiology is a possibility, the majority of theories credit cancer development as a process resulting from cell damage induced by outside influences, called carcinogens (Yarbro et al., 2018). Carcinogens are substances, radiation, or exposures that can damage the genetic material (DNA) throughout one's lifetime, resulting in carcinogenesis, or the formation of cancer (Itano, 2016). A few examples of carcinogens include tobacco smoking, tanning beds, diesel exhaust, and ultraviolet radiation (Polovich et al., 2014). Age is the most outstanding risk factor for cancer, as the incidence of cancer rises alongside age (Nettina, 2019). Other risk factors include exposure to chemicals, viruses, poor nutrition, diets high in fat, obesity, sedentary lifestyles, and excessive alcohol intake (Yarbro et al., 2018). Primary prevention and secondary prevention are effective measures in decreasing mortality and morbidity of many cancers. The ACS (2018b) recommends specific primary and secondary prevention measures to reduce an individual's risk of cancer death.
A substantial proportion of cancers can be prevented through primary cancer prevention, which involves minimizing harmful exposures and reducing or omitting unhealthy lifestyle behaviors. ACS (2018b) researchers have determined that approximately 42% of newly diagnosed cancers in the United States are potentially avoidable, as they are directly correlated with tobacco use, obesity, sedentary lifestyle, and other modifiable behaviors. Tobacco is the single most significant cause of cancer-related deaths and is attributed to more than 480,000 deaths annually, 42,000 of which are related to secondhand smoke (Nettina, 2019). Tobacco use is associated with many types of cancers, including cancers of the lung, bladder, head and neck, kidney, cervix, liver, and pancreas. Skin cancers are primarily due to excessive sun exposure and indoor tanning beds, and prevention strategies focus on the application of proper sunscreen, lightweight clothing, and hats to shield oneself from direct exposure, reducing sunlight exposure during peak hours of the day when the ultraviolet rays are the strongest, and avoiding tanning beds altogether (Polovich et al., 2014). Infections and viruses are associated with an increased risk of certain forms of cancer, such as hepatitis B, hepatitis C, and hepatocellular cancer (Nettina, 2019). Cancers related to the human papillomavirus (HPV) can be prevented through behavioral and lifestyle changes, as well as through vaccination (Nettina, 2019). According to the Centers for Disease Control and Prevention (CDC, 2019), 80% of people will get an HPV infection in their lifetime, and approximately 14 million Americans become infected with HPV each year. HPV can cause cancers of the cervix, vagina, vulva, throat, tongue, and tonsils. The U.S. Food and Drug Administration (FDA) approved HPV vaccination, Gardasil9, can protect against over 90% of HPV cancers and genital warts (CDC, 2019).
Secondary Cancer Prevention
Secondary cancer prevention involves partaking in activities such as screenings and testing to identify those at high-risk who require increased surveillance as compared to the general population (Yarbro et al., 2018). These measures can prevent cancer through the identification of precancerous lesions and by taking appropriate action before the cells develop into invasive cancer; or by undergoing interventions, such as prophylactic mastectomy in an otherwise healthy patient with a BRCA mutation to diminish the lifetime risk of breast cancer development. Screenings allow for the early detection of cancers when they are still treatable or potentially curable. Examples of cancer screening tests include colonoscopy, sigmoidoscopy, fecal occult blood testing (FOBT), mammography, Papanicolaou test (pap smear), prostate specific antigen (PSA), and digital rectal exam (DRE). Some institutions are now offering cancer-screening programs with low-dose spiral computed tomography (CT) scans to detect curable stage I lung cancer in patients who meet the designated criteria. The goal of screening is early detection to improve overall outcome and survival. The decision to perform routine screening tests should be based on whether these tests are adequate to detect a potentially curable cancer in an otherwise asymptomatic person and are cost-effective. Screening should be based on an individual's age, sex; family history of cancer, ethnic group or race, previous iatrogenic factors (prior radiation therapy or drugs such as DES), and history of exposure to environmental carcinogens (Yarbro et al., 2018).
The oncology nurse plays a critical role in the assessment and reduction of risk factors before the disease occurs, and educating patients on the importance of making specific lifestyle changes, as well as education on critical screening measures for the early detection of cancer. Essential training and teaching points are outlined in Table 1, as adapted from the ACS Prevention and Early Detection Guidelines (2018b).
Table 1. Key Teaching Points: Cancer Prevention and Early Detection
*average risk refers to guidelines for the general population; those at higher risk (such as strong family history, concerning symptoms, or other risk factors) should consult their physician for individualized screening guidelines
The Relationship between Obesity and Cancer
Many patients are not aware of the impact of excess body fat and obesity on cancer development, progression, and cancer recurrence. Obesity, a well-known major global health challenge, is objectively measured as a body mass index (BMI) of 30 or higher, and defined by excess fat accumulation in relation to height. Despite its negative impact on health, obesity rates are still expected to rise substantially over the next several decades (World Health Organization [WHO], 2016). The World Cancer Research Fund (n.d.) estimates that about 20% of all cancers diagnosed in the United States are related to excess body weight, physical inactivity, and poor nutrition; and aside from tobacco use, these are the three most crucial cancer risk factors that can be modified. One prime example of the relationship between cancer and obesity is endometrial (uterine) cancer. Endometrial cancer is the most common gynecologic malignancy, with an estimated 61,880 new cases to be diagnosed in the United States in 2019, and 12,160 predicted deaths (Surveillance Epidemiology and End Results Program [SEER], 2017). Historically recognized as a disease of postmenopausal women with a strong association with obesity, endometrial cancer is now becoming much more prevalent in the younger, premenopausal population, ranking as the fourth most common cancer among women in the United States. The increased incidence is mostly attributed to the global obesity epidemic, and the resulting metabolic disorder, with obesity cited as being responsible for up to 81% of all endometrial cancers diagnosed worldwide (Moore & Brewer, 2017). This striking statistic demonstrates the detrimental effect of obesity on cancer occurrence. The underlying etiology is premised on an exposure-response relationship between excess fat tissue and endometrial cancer risk, which is driven by an overproduction of estrogen (hyperestrogenism) carried in adipose tissue, insulin resistance, increased bioavailability of steroid hormones, and inflammation (Moore & Brewer, 2017). These processes generate a metabolic state that drives tumorigenesis (Papatla, Huang, & Slomovitz, 2016). For those already diagnosed with endometrial cancer, obesity not only leads to poorer long-term health outcomes, but it is also found to impact the treatment course negatively. Despite a clear understanding of the relationship between obesity and endometrial cancer, mortality from obesity-driven comorbidities continues to rise. Obese women with endometrial cancer are more likely to die from other obesity-related diseases than endometrial cancer (Jenabi & Poorolajal, 2015). These conditions are some of the leading causes of preventable death, including heart disease, stroke, and type II diabetes (ACS, 2018a).
Cancer Signs and Symptoms
The presenting signs and symptoms of cancer can vary widely depending on the type of cancer. A patient may be asymptomatic at the time of diagnosis, or signs may be extremely vague and nonspecific; prolonging the time of symptom presentation until a definitive diagnosis is determined. Some cancers, such as leukemia and lymphoma, often exhibit a cluster of symptoms that suggest the diagnosis, such as constitutional symptoms of unexpected weight loss, night sweats, lymphadenopathy (enlarged lymph nodes), and excessive fatigue. However, the complexity of cancer diagnoses is that many of the presenting symptoms are similar to symptoms of various non-malignant illnesses, such as viruses or tick-borne diseases. Some warning signs of cancer that should always warrant evaluation by a clinician include rectal bleeding, vaginal bleeding in postmenopausal women, a lump in the breast, abdominal bloating or distension that does not resolve, unexplained weight loss, or a productive cough with hemoptysis (blood-streak sputum or coughing up blood clots). Cancer may present in many other ways, so a thorough history taking and physical assessment are critical (Yarbro et al., 2018).
Cancer Diagnosis and Staging
To diagnose and stage cancer, patients must undergo a series of tests to determine the origin of cancer, the pathology and histologic type of cancer, and evidence of any spread of cancer to distant sites. All patients must undergo some form of tissue sampling, usually a biopsy, to establish a pathologic tissue diagnosis. This information is an essential component of planning the definitive treatment plan, as it determines with certainty the cell type, histology, and grade of the tumor. A few examples of tumor types include carcinoma, sarcoma, lymphoma, and glioma. Classification of tumor type is based on tissue and cellular staining, which helps distinguish one cell type of cancer from another. The grade of the tumor (ranging from 1 to 4) refers to the degree to which a malignant cell is similar to healthy tissue. In other words, the grade is based on how well-differentiated the cells appear, or how closely the tumor cell resembles healthy cells. The higher the grade, the less differentiated the cancer is. Poorly differentiated cancers contain few features of healthy tissue, are more aggressive, and carry a poorer prognosis overall. Special stains are performed to determine specific markers or proteins that may help guide treatment. In addition to biopsy, another sampling method important in establishing a cancer diagnosis includes cytology specimens, as malignant cells can be found in body fluids such as ascites and pleural effusions. Additional cellular and genetic features are also increasingly identified to define the final diagnosis further and guide newer treatment options, such as immunotherapy and targeted agents. The tissue sample can be obtained through a few different techniques. Patients may undergo a fine-needle aspiration (FNA), which is a procedure in which cancer cells are aspirated from the tumor using a needle and syringe. A significant limitation of the FNA is that it cannot distinguish invasive from noninvasive cancer, and negative results do not entirely rule out malignancy. Therefore, a core-needle biopsy is more commonly performed. This technique utilizes a large-bore needle placed directly into the tumor, usually through ultrasound or computed tomography (CT) guidance, to retrieve a small piece of the intact tumor. This generally provides enough tissue to diagnose most types of cancer adequately. It is considered a highly accurate procedure and is usually performed in the outpatient setting. Other times, tumor samples may be retrieved through surgical intervention and open biopsies performed in the operating room when patients are under anesthesia (Yarbro et al., 2018).
Radiology imaging such as CT scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans are another vital component of the cancer staging workup. These tests are used to determine evidence of and/or extent of metastasis. Additional testing depends on the cancer diagnosis. Staging is necessary at the time of diagnosis to determine the extent of disease, to assess prognosis, and to guide proper management. Accurate staging provides a collection of data that informs decision making about treatment and guides treatment outcomes for each type of cancer. The American Joint Committee on Cancer (AJCC) has developed a simple classification system that can be applied to all tumor types, called the tumor-node-metastasis (TNM) staging system. The TNM is preferred for most solid tumors and is a numeric assessment of tumor size (T), presence or absence of regional lymph node involvement (N), and presence or absence of distant metastasis (M). However, there is not a single standard evaluation tool that exists for all cancers. Hematologic malignancies are staged differently than solid tumors. For example, Hodgkin and Non-Hodgkin lymphoma is staged with the Ann Arbor Classification, whereas gynecologic malignancies rely on the International Federation of Gynecology and Oncology (FIGO) staging system. In general, the workup depends on the patient, tumor type, symptoms, and medical knowledge of the natural history of each cancer (Yarbro et al., 2018).
Tumor markers are substances, or proteins, secreted by certain cancers that can be found and measured in the bloodstream or urine. While tumor markers are considered non-specific and are not much benefit in isolation, they can be beneficial when evaluating response to treatment and monitoring for cancer recurrence. Some common tumor markers include carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), and cancer antigen 27-29 (CA 27-29). Each tumor marker is specific to a different type of disease process. For instance, PSA relates to prostate cancer, whereas CEA is commonly used for cancers of the rectum, colon, pancreas, and breast, and CA 27-29 is associated with breast cancer (Yarbro et al., 2018).
Nursing Implications of Cancer Diagnosis
A cancer diagnosis is a stressful, life-altering event, routinely accompanied by substantial physical, psychological, and social implications for both the patient and their family. The oncology nurses' role when a patient is diagnosed with cancer centers on two main domains: to be informative and supportive. Not only do oncology nurses help patients navigate through the diagnosis and staging workup process, but they are also the patient's tour guides into a different field of their health. Oncology nurses must be equipped to answer questions that will inevitably arise once a patient has been diagnosed with cancer. Most patients and families are overwhelmed during this time, stricken with anxiety and fear, which heightens the significance of support, education, and teaching. Oncology nurses also understand that patients will rarely be able to retain all of the information presented to them by the physician, and will often feel confused, overwhelmed, and panicked at the end of the appointment, or during the days after. Therefore, oncology nurses spend a great deal of time clarifying misunderstood information and reinforcing the patient's prior conversations with their oncologist. The nurse must be prepared to address the patient's questions about the general disease process, prognosis, further testing, and treatment options. Nurses should explain the rationale for the staging process, and why specific tests were ordered, how they are performed, and any appropriate preparation procedures required for the tests. Skilled nurses understand their role in advocacy for the patient, and if unable to answer the patient's questions, they utilize their position to seek clarity from the oncologist on the patient's behalf (Neuss et al., 2016).
A cancer diagnosis not only affects the patient; it impacts the entire family. Cancer causes fear, uncertainty, and anxiety. Patients may initially feel powerless or hopeless or may experience grief over life plans that have been altered by the disease. Patients need guidance and emotional support from oncology nurses throughout the cancer care continuum, starting at the time of diagnosis. The oncology nurse's role in providing psychological support is multifaceted and incorporates listening to, guiding, reassuring, and supporting patients through the early stages of grief. Very similar to the ways in which people mourn the death of a loved one, many patients will grieve the loss of their health. This may be the first time the patient is faced with his/her mortality and will often need compassion, empathy, and assistance navigating through these distressing emotions. If the patient is exhibiting signs of emotional distress, poor coping, or other psychological difficulties related to their cancer diagnosis, the oncology nurse should additionally consider referring the patient to a social worker, chaplain, therapist, or cancer support group. The nurse must also develop strong interpersonal skills, engage in active listening, assess the patient's understanding of the disease process, and evaluate the patient's emotional state on a regular and recurring basis. Oncology nurses play a tremendous role in supporting the patient throughout their cancer journey (Nettina, 2019).
The Four Goals and Four Treatment Modalities
The method of cancer treatment depends on the type of cancer, the stage, presence of metastasis, and condition of the patient. There are four main goals of cancer therapy, which include: prevention, cure, control, and palliation (Yarbro et al., 2018). While prevention focuses on taking measures to preclude the development of cancer, cure denotes treatment given to eradicate the disease. Control refers to the extension of a patient's life when a cure is unlikely or impossible by preventing the growth of new cancer cells and reducing the size and impact of existing disease. Palliation focuses on comfort when the cure and control of the disease cannot be achieved. It is important for oncology nurses to have ongoing discussions with patients regarding their personal goals of care and whether or not those goals are being achieved and/or are achievable. In addition to the four goals of care, there are four primary modalities of cancer treatment, which are essential for nurses to understand. These include surgery, radiation, chemotherapy, and biologic therapies as seen below in Figure 1 (Nettina, 2019).
It is common for cancer patients to undergo a combination of treatment modalities throughout their disease trajectory. Scientific advancements and treatment breakthroughs have revolutionized how cancer is managed, leading to innovative fields such as precision (or personalized) medicine and the development of targeted therapies and immunotherapy. Precision medicine uses the genomic profiling of a patient's tumor to identify genetic mutations that are unique to the tumor (Yarbro et al., 2018). Targeted therapies block the growth and spread of cancer by interfering with specific genes, proteins, and/or blood vessels that allow cancer cells to replicate, grow, and spread. Immune-based treatments assist the body's own the immune system in identifying cancer cells and attacking them in the same manner it would work for any other infection, virus, or other potential threat (Milioutou & Papadopolou, 2018). Radiation therapy is a localized treatment that has become more precise and effective over time; however, it still carries a slew of associated side effects and toxicities. Surgery is not indicated in all cancers, but clinical research has helped to define better the parameters and indications for surgical intervention, as well as the ideal time for the patient to undergo surgery (Yarbro et al., 2018).
The National Comprehensive Cancer Network (NCCN, 2019a) is an alliance of leading cancer centers and world-renowned experts devoted to cancer care, research, and education. Through rigorous clinical trial research, data compiled across institutions, and annual expert panel review, the NCCN provides evidence-based treatment guidelines according to cancer type, pathology, genetics, staging, inheritance patterns as well as several other specific features. The guidelines are widely utilized in cancer care and guide medical decision-making throughout the patient's disease trajectory (NCCN, 2019a).
Surgical management of cancer is commonly performed for tumors that are confined locally and/or regionally. For cancers that grow slowly, remain local and confined, surgery has a greater chance of removing the tumor, providing control, or even cure of the disease. In these cases, surgery is performed with curative intent, as the goal is to remove all or a portion of the primary tumor. It may be the only treatment a patient requires, or it may be used in conjunction with other modalities. There are other times when surgery is used in the palliative setting, as a means of reducing and alleviating distressing cancer symptoms. The role of surgery can be divided into several approaches: preventive, primary surgery, cytoreductive surgery, salvage treatment, palliative treatment, and reconstructive (Yarbro et al., 2018). Refer to Table 2 for an outline of the role of the various types of surgical intervention for cancer treatment.
Table 2. Surgical Treatment of Cancer
Cytoreductive (debulking) Surgery
(Yarbro et al., 2018)
Surgical intervention may also be used in combination with other treatment modalities, such as preoperative chemotherapy, intraoperative chemotherapy, radiation therapy, or postoperative (adjuvant) systemic treatment. The severity of side effects depends upon the type and dose of treatment modality. For instance, certain chemotherapy agents may delay wound healing, whereas others may impact cardiac function, imposing complications on surgery (Yarbro et al., 2018).
The nurse's role extends throughout the surgical continuum, from pre-surgical counseling and preoperative care, through the postoperative period and cancer survivorship. Surgical oncology nurses serve vital functions in the preparation, education, symptom management, post-operative recovery, and follow-up care of surgical patients. Their responsibilities are broad and may include obtaining pertinent medical history, allergies, and reviewing surgical consent. Nurses are primarily responsible for the majority of pre-surgical counseling and teaching, which includes how to prepare for surgery, infection control measures, what to expect during the surgery, and education on the recovery period, including the care of surgical wounds. During the postoperative teaching period, nurses provide instructions regarding the use of any equipment required, pulmonary exercises, and pain management options. Nurses serve critical roles in managing anxiety as well as providing emotional and psychosocial support to patients and families during this highly stressful period of uncertainty (Nettina, 2019).
Patients undergoing surgery often endure different symptoms and side effects, requiring nurses to be vigilant to manage adverse events. Nurses in the postoperative environment must understand the disease processes, manage postoperative symptoms such as pain and nausea, and are responsible for monitoring the surgical site and wound care. They are trained in interventions to decrease the incidence and severity of complications unique to surgery, such as airway clearance and skin integrity. Nurses teach patients coughing, deep breathing, and demonstrate the use of incentive spirometers to prevent pneumonia and lung infections. They may use suction to aid in airway clearance of secretions or sputum and reposition patients in bed every two hours to avoid pressure ulcers and skin breakdown. Nurses teach splinting of the incision with coughing, sneezing, or movement to reduce pain and prevent wound dehiscence. They administer pharmacologic pain medications as ordered by the medical provider and advocate for patients displaying signs of discomfort, such as grimacing or grunting, who are unable to advocate for themselves. Nurses must also monitor for signs and symptoms of infection during the postoperative period, such as fevers, redness, drainage, swelling, or warmth to the incision site. The nurse must be attuned to the status of the surgical wound bed and promptly report suspicious changes or concerns to the provider. Also, patients with cancer are often considered hypercoagulable, which is an increased tendency toward blood clotting, thereby enhancing their risk for a blood clot. Nurses must ensure patients receive appropriate venous thromboembolism (VTE) prophylaxis with the use of sequential compression devices (SCDs) or compression stockings. Further, nurses should encourage early mobility and adequate hydration of patients in the postoperative period to further reduce the risk of VTE. Nurses must ensure appropriate monitoring of patients for signs of thrombosis, such as unilateral leg swelling, calf or knee discomfort, redness, warmth, shortness of breath, hypoxemia, or tachycardia. These symptoms must be promptly reported to the provider, as they can quickly progress and lead to fatal outcomes. Surgical nurses often manage many invasive tubes, drains, and catheters in the postoperative period. Cautious assessment and monitoring of each site are crucial to identify acute signs of infection or other complication. Surgical complications may include infection, bleeding, thrombosis, bowel obstruction or ileus, acute respiratory distress syndrome, aspiration pneumonia, and cardiac dysfunction (Yarbro et al., 2018).
Nurses serve an equally vital role in inpatient and family education, and therefore, must be skilled at closing educational gaps and ensuring all the patient's needs (physical and emotional) are addressed before discharge. Patients and their caregivers must understand the details of how to administer prescribed medications, dosing schedules, ongoing wound care, and signs and symptoms of infection. Nutrition is a critical aspect of the postoperative period, as it has implications in wound healing, infection control, and overall prognosis. Protein and caloric malnutrition are common issues in cancer patients who have undergone prior treatment or have a compromised immune status, leading to complications such as wound dehiscence, sepsis, and longer hospitalizations. Management of any temporary or permanent lines, catheters, or body alterations, such as ostomy care, must be reviewed. Communication with home health agencies providing care to the patient after discharge from the hospital is also imperative to ensure adequate understanding of postoperative instructions and a seamless transition without disruption in necessary care. Patients may experience a significant emotional component when undergoing surgery, and many patients formally learn of their cancer diagnosis during their postoperative recovery. Oncology nurses are in a unique position to defuse distressing events and reinforce patient and family education. Nurses are responsible for ensuring patients understand discharge instructions, are well versed in signs and symptoms of postoperative infection warranting medical attention, as well as have a proper plan for oncologic follow up (Yarbro et al., 2018).
Radiation therapy has dramatically evolved since the original use of Cobalt therapy machines in the 1950s. Scientific advancements have led to the development of computers for treatment planning and dose optimization, which assist in minimizing treatment-related toxicities (Yarbro et al., 2018). Radiation plays a significant role in many types of cancer, with greater than 60% of cancer patients receiving radiation at some point during their disease course. Radiation therapy is a type of localized cancer treatment that uses ionizing radiation to treat cancerous tumors, with the primary objective of delivering a precisely measured dose of radiation to a defined tumor with as little injury as possible to surrounding healthy tissue. Radiation induces cellular damage to cancer cells, leading to biological changes in the DNA. This causes cells to die over days, weeks, and months, rendering them incapable of reproducing or spreading. All healthy cells and cancer cells are vulnerable to the effects of radiation and may be injured or destroyed; however, most normal cells can repair themselves and remain functional. Rapidly dividing cancer cells, such as lymphomas and squamous cells of the head and neck, tend to be more sensitive to the effects of radiation than those that divide more slowly, such as sarcoma. The goal is either the eradication of the tumor, palliation of symptoms, improvement in the quality of life, or prolonged survival, with as minimal morbidity as possible (DeVita, Lawrence, & Rosenberg, 2015). Once again, the NCCN guidelines are an essential component to the radiation treatment plan, as these guidelines define the exact indications for radiation therapy premised on the type and stage of cancer, and delineate at which point during the disease trajectory the radiation should be administered (NCCN, 2019b).
Radiation may be the only treatment approach required for some cancers, whereas it may be used as part of a combined multimodality approach for other cancers. Some patients will receive concurrent chemoradiation, in which chemotherapy is administered to act as a radiosensitizer, thereby making the cancer cells more vulnerable to the effects of radiation. Other patients may receive radiation after the completion of chemotherapy treatment or surgery. Patients who undergo surgery for the removal of a cancerous tumor may need to receive adjuvant radiation to the affected area after surgery. This commonly occurs in breast cancer patients who undergo lumpectomy to remove the tumor, and then go on to receive radiation to ensure all cancer cells are eradicated. Palliative radiation may be given to shrink the size of a tumor, reducing pressure on surrounding tissues, and thereby alleviating pain. In patients with primary spinal cord tumors or metastatic disease to the spine, palliative radiation is typically used to ease back discomfort or relieve neuropathy or neurologic paresthesia as a consequence of the tumor pressing on the nerves or the spinal cord. It is also given to offset the clinical course of cancer that has progressed to the spine; which poses significant potential for debilitating neurologic compromise. In these cases, radiation is not only given to control pain, but also to stunt the growth of the spinal lesions, reduce their size and impact on surrounding structures, as a means of preventing or delaying devastating effects. Palliative radiation for brain tumors can shrink the tumor size, thereby reducing symptoms such as headache, nausea, vomiting, or visual disturbances. Palliative radiation has more flexibility than traditional radiation regimens, so treatment plans vary widely, but they are usually shorter in duration, and are primarily focused upon reducing symptom burden (Yarbro et al., 2018).
The total dose of radiation is hyper-fractionated, which means it is administered in smaller divided doses, or fractions, rather than all at once. Hyper-fractionation allows healthy cells a chance to recover between dosing. Each dose is called a fraction, and while there are a variety of treatment plans, patients usually receive daily treatments over several weeks with weekend breaks. The weekend break allows for repair and repopulation of surrounding healthy tissue, as a means of reducing toxicity and side effects, while still gaining control of the disease. The total number of fractions administered depends on the tumor size, location, cancer type, reason for treatment, patient's overall health, performance status, goals of therapy, as well as consideration of any other treatments the patient is receiving. Radiation can be delivered externally or internally, and some patients may receive both types. Internal radiation is further subdivided into two categories: brachytherapy and radioactive liquid or injection (Nettina, 2019). See Table 3 for a comparison of the types of external and internal radiation therapy.
Before any type of radiation treatment begins, patients must first undergo a treatment simulation, which maps out the exact point the radiation will be delivered. A pinhead-sized permanent tattoo is usually placed on the patient's body. When the simulation plan is completed, the radiation oncologist reviews all the data and multiple validations of the treatment plan are performed to ensure high-quality and appropriate treatment. While there are some forms of radiation therapy administered within the inpatient setting, most are delivered on an outpatient basis in hospital-based radiation departments or free-standing radiation facilities. Once treatment begins, daily treatments average less than 15 minutes in duration each, and most people can schedule radiation treatments around their regular workday schedules (Nettina, 2019).
Table 3. External Radiation vs. Internal Radiation
External Beam Radiation
Intensity-Modulated Radiation Therapy (IMRT)
Image-Guided Radiation Therapy (IGRT)
(NCCN, 2019b; Yarbro et al., 2018)
LDR brachytherapy usually requires hospitalization for several days, during which time the patient is confined to an isolated, radiation-safe room to protect others from exposure to the radiation. Specific LDR treatments involve the placement of radioactive rods, which require the patient to be confined to a bed to prevent dislodgment of the applicator for a defined period (usually 1-3 days). LDR brachytherapy is more commonly performed with certain types of prostate cancer requiring implanted seeds, oral cancers, and cervical cancer. HDR brachytherapy has distinct differences from LDR and is generally performed on an outpatient basis. Each treatment lasts only minutes, and hospitalization and bed rest are not indicated. Further, staff, visitors, and family members are not exposed to any radiation. The treatment is delivered in a radiation-shielded room to protect others from exposure, and patients are not considered "radioactive" after each treatment. They can safely go about their regular routines and lifestyles without potentially exposing others. HDR brachytherapy is used for the treatment of many types of cancers, such as lung, breast, and esophageal cancers (NCCN, 2019b).
Two additional types of radiation therapy that do not entirely fit into the above categories include intraoperative radiation therapy and stereotactic radiation, or radiosurgery. Intraoperative radiotherapy is given during surgery for tumors that are not wholly operable or are at high risk for recurrence. This is most commonly performed with gynecologic cancers and colorectal cancers. Radiosurgery is generally used for brain tumors. The radiation beam is delivered precisely to the tumor itself, sparing the surrounding healthy brain tissue. This can be administered through a procedure called a gamma knife, during which the patient's head is placed into a frame and secured with screws, while specialized scanning technology allows for precise and accurate delivery of radiation to the cancerous tumor (Yarbro et al., 2018).
Federal and state regulatory agencies govern the use of radioactive substances and have established strict guidelines for safety, exposure, and maximum permissible doses for radiation oncology nurses. Therefore, nurses caring for patients undergoing LDR brachytherapy must wear special badges that record radiation exposure and undergo extensive training in the critical components of radiation safety. Nurses must remain vigilant about the three cardinal radiation principles of time, distance, and shielding to protect themselves from exposure (Nettina, 2019). Time refers to minimizing the time spent near the source. Nurses are taught to cluster nursing activities to reduce time spent in direct patient contact and maximize distance from the source. Shielding refers to the use of protective barriers between the radiation source and the nurse whenever possible (DeVita et al., 2015). For instance, if the nurse must attend to the patient's needs at the bedside, aside from clustering activities, she uses specialized personal protective equipment to shield herself from the radioactive source (NCCN, 2019b). The nurse is also responsible for educating the patient and family members on appropriate safety measures, limiting the contact of family members with the patient during this time, as well as providing emotional and psychological support to the patient, who often feels lonely and isolated. For the subset of patients who are considered ‘radioactive' due to seeds or implanted devices when they are discharged into the community, healthcare providers and radiation oncology nurses play critical roles in educating these patients on the risk posed to others in the community. Nurses have a moral and ethical obligation to limit exposure to those in the community by ensuring necessary safety and risk-reducing precautions are fully understood by the patient and caregiver (Yarbro et al., 2018). Patients must be instructed to avoid young children and pregnant women, especially during the time it takes for the implant's radioactivity to decay to safe levels. This is a period of time that varies with the type of radioactive material in the implant and should be determined and then explained to each patient individually based on his or her treatment regimen (DeVita et al., 2015). Policies and regulations are also in place to protect radiation oncology nurses and other radiation personnel who may be pregnant. In general, policies discourage pregnant personnel from caring for patients receiving radiation, and nurses are advised to immediately notify their supervisor if they have become pregnant, or are trying to get pregnant (NCCN, 2019b).
Nursing Implications in Radiation Therapy
The ONS offers an international web-based continuing education course, called the ONS/ONCC Radiation Therapy Certificate Course, which oncology nurses practicing in radiation specialties are strongly encouraged to complete (ONS, 2019b). While teaching is a primary responsibility of the radiation oncology nurse, as safety is of utmost concern in this patient population, nurses also play a vital role in symptom management. Radiation can produce several side effects, both acute and latent, which are primarily dependent upon the targeted location and the dose. Since radiation therapy is a localized treatment, side effects will generally only occur at or immediately surrounding the site of radiation (Nettina, 2019). The most common side effects associated with all locations of radiation include skin reactions (external skin and/or mucous membranes) and fatigue. Radiation targeting lesions on or near the spine can induce bone marrow suppression such as neutropenia, anemia, and thrombocytopenia as a consequence of the proximity to the areas in the body where bone marrow is produced. Radiation targeting the gastrointestinal tract, such as the stomach, colon, or rectum, can induce nausea and diarrhea, painful defecation, fluid volume deficit, and electrolyte disturbances, leading to weight loss, and skin breakdown. Radiation for head and neck cancer is known to cause significant complications with oral intake due to sore throat, oral ulceration (mucositis), stomatitis (ulceration of the esophagus), dysphagia (painful swallowing), and xerostomia (dry mouth). These patients often require placement of a feeding tube to ensure adequate nutrition and prevent cachexia. Since nutrition is such a critical component of cancer treatment and largely influences the patient's response to therapy and potential toxicity, many radiation oncologists will prophylactically order the placement of a percutaneous endoscopic gastrostomy (PEG) tube before the start of radiation therapy in patients at high risk for malnutrition during therapy. Radiation to the breast or chest wall can sometimes impact the heart and lungs leading to late effects such as cardiotoxicity (damage to the heart function or muscle) or pulmonary fibrosis (scarring of the lungs). Radiation to the cervix and vagina can lead to vaginal atrophy, inducing symptoms of vaginal dryness, irritation, scarring, and sexual dysfunction. Radiation fields that affect the bladder can cause cystitis (inflammation of the bladder) leading to dysuria (painful urination), hematuria (blood in the urine), urinary incontinence, and loss of pelvic floor muscular strength (DeVita et al., 2015; Yarbro et al., 2018).
Acute Effects of Radiation
The acute effects of radiation are usually transient and occur during treatment and generally subside within 1-2 weeks of treatment cessation. The affected areas are typically the tissues with rapid renewal characteristics and quick cell turnovers, such as the skin, mucous membranes, and bone marrow, as described above (DeVita et al., 2015). Advancing age, nutritional status, and prior treatment or concurrent chemotherapy often impacts the severity of symptoms. Fatigue and anorexia are the most common generalized effects. Other acute effects are site-specific and may include: gastritis, esophagitis, colitis, nausea, mucositis, xerostomia, taste alterations, pharyngitis, alopecia, lymphedema, vaginal dryness, and sexual dysfunction (Nettina, 2019).
Skincare is critical in patients undergoing radiation as up to 95% of patients receiving radiation therapy will experience some degree of skin reaction. Radiation oncology nurses play an essential role in educating, assessing, and monitoring patients for radiation dermatitis, or radiodermatitis. This condition occurs in response to ionizing radiation exposure and is caused by changes to the basal layer of the epidermis and the dermis. Cumulative doses of radiation weaken the skin integrity, depleting stem cells from the basal layer of the epidermis, leading to varying degrees of radiodermatitis. Acute skin reactions generally begin around 7-14 days after the initiation of treatment, and the first signs include dryness and slight erythema. These symptoms may progress to bright red erythema, rash, and desquamation as treatment progresses. Patients often describe that the skin feels similar to sunburn. Several patient factors heighten the risk of skin reactions during radiation therapy, such as poor nutrition, skin folds occupying the radiation field, sun exposure, and use of topical irritants. Desquamation is the sloughing off of the top layer of the skin and involves two stages; dry and moist. The first stage, dry desquamation, is the peeling of the top layer of skin and becomes increasingly uncomfortable as the underlying nerve endings are exposed to air. It is most common in intertriginous areas, or skin that rubs against each other, such as beneath the breast or axillae. Moist desquamation refers to the peeling of the skin with the addition of serous fluid leakage and is very uncomfortable for patients. The radiation oncology nurse's role in skincare relating to radiation is imperative and involves comprehensive assessment, along with the appropriate and timely delivery of evidence-based interventions. The nurse must also clearly convey education and teaching to patients to ensure an adequate understanding of skincare to minimize skin reactions (Yarbro et al., 2018).
The effects of radiodermatitis can impact a patient's quality of life, induce pain and discomfort, limit activities, and delay treatment. Depending on the severity of the reaction, radiodermatitis may also cause interruption of or cessation of treatment altogether. Unfortunately, due to the nature of a cancer diagnosis requiring radiation, preventing all skin reactions caused by radiation therapy is generally not possible, particularly in conditions such as inflammatory breast cancer, where intense skin reactions are expected. Therefore, it is essential for radiation oncology nurses to have a keen understanding of the assessment, documentation, grading, and management of radiation dermatitis (Yarbro et al., 2018). There are several grading tools available for use when evaluating radiodermatitis and selection can vary across treatment facilities and physician preference. A few of the most commonly used tools include: (a) the Radiation Therapy Oncology Group (RTOG) Acute Radiation Morbidity Scoring Criteria; (b) the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 5.0 (NCI, 2017); (c) the ONS Radiation Therapy Patient Care Record; and (d) the Radiation-Induced Skin Reaction Assessment Scale. Regardless of which scale is chosen for use, the same scale should be consistently applied to the patient to ensure the assessment and documentation of the progression are reliable and accurate (DeVita et al., 2015). The management of radiation dermatitis is complex and varied, and currently, no gold standard exists for the prevention or management of radiodermatitis. However, expert opinion and consensus have formulated fundamental guidelines for radiation oncology nurses to follow, which are outlined in Table 4 below (Yarbro et al., 2018).
Table 4. Skin Care Management
Healthcare Provider Precautions
Key Teaching Points
Skin Irritation, Rash and/or Pruritus
Patient Personal Hygiene
(Yarbro et al., 2018).
Radiation recall is a severe skin reaction that occurs when certain chemotherapeutic drugs are administered during or soon after radiation treatment. It is an inflammatory reaction at a previously irradiated site triggered mostly by an antineoplastic agent, though the mechanism of the response is poorly understood (DeVita et al., 2015). It usually affects the part of the body that received radiation, especially the skin. The rash appears like severe sunburn with redness, swelling, and tenderness. The skin may blister and peel, and discoloration of the skin may occur after it heals. Radiation recall can occur weeks, months, or even years after radiation therapy has ended. Treatment generally consists of corticosteroids to reduce inflammation, and rarely, delay of chemotherapy until the skin heals (Benyounes, Pathak, Binder, & Hausner, 2018).
Late Effects of Radiation Therapy
Delayed effects are usually considered to be those effects that appear more than two months (in many cases, years) after the exposure. Newer methods of radiation therapy have helped to minimize damage to healthy tissue; however, treatment is directed to the same area each time, and radiation rays sometimes scatter. Tissues and organs near the cancer site might receive small doses of radiation despite efforts to prevent this. Late effects of radiation are generally premised on the location of the radiation treatment site and the dose/duration of treatment. Some late effects may include cataracts, permanent hair loss, or problems with memory or the ability to learn for those treated with brain/cranial radiation. Others many endure issues with thyroid or adrenal glands. Hypothyroidism is one of the more common late effects of radiation therapy when radiation treatment involves the neck, head, and chest. Radiation-induced heart disease is a side effect of radiation therapy to tumors in the chest when all or part of the heart is situated in the radiation field and may include cardiomyopathy, congestive heart failure, and damage to the heart muscle inducing an overall decline in cardiac function. Radiation to the posterior chest wall may cause lung complications such as pulmonary fibrosis and interstitial lung disease. Infertility, sterility, and sexual dysfunction are also common delayed and ongoing effects of radiation. Some patients may sustain a decreased range of motion in the treated area due to scarring and loss of elasticity of tissue. Vaginal dilators are recommended for patients who have undergone radiation therapy to the vagina. Pelvic floor training exercises (Kegel exercises) are advised for patients experiencing urinary dysfunction, such as incontinence or loss of sphincter tone, as a means of strengthening the muscles of the pelvic floor. Edema and lymphedema are potential side effects due to the disruption of the lymphatic system. Skin sensitivity with sun exposure to the affected area may be present for life, so patients must be counseled on sun safety practices. Young children who have undergone radiation treatment may exhibit slowed or halted bone growth (Boerma et al., 2016).
Radiation-induced Secondary Malignancies (RISM)
Radiation-induced secondary malignancies (RISM) is an important late side effect of radiation therapy, as after surviving a primary malignancy, about 17%–19% patients go on to develop a second malignancy, and about 5% of these are related to radiation therapy (Morton, Onel, Curtis, Hungate, & Armstrong, 2014). While this is a relatively low risk, it warrants attention and understanding. The exact mechanism is unknown but generally occurs 10 to 15 years after the original tumor was treated, is histologically different from the primary tumor, and arises within the previously irradiated tissue (Dracham, Shankar, & Madan, 2018).
For more information on chemotherapy and oncologic emergencies, please refer to the second part of this module series, Oncology Nursing Part 2: Chemotherapy and Oncologic Emergencies, which includes 5.0 ANCC contact hours.
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