NLE Oncology Nursing — Cancer Pathophysiology, Prevention and DetectionRevision Notes

Exam Tips

• Remember: Proto-oncogene = NORMAL gene. Oncogene = MUTATED, bad. Think of it as 'proto' meaning 'before it went wrong.'
• p53 is a tumor SUPPRESSOR — it SUPPRESSES cancer. When p53 is lost, cancer is UNLEASHED. This distinction appears frequently in NLE items.
• NLE items may describe a cell that 'fails to undergo apoptosis' — the answer is always related to tumor suppressor gene failure or oncogene activation.

Key Points

• Normal cells exhibit CONTACT INHIBITION — they stop dividing when they touch neighboring cells. Cancer cells lose this ability.
• APOPTOSIS (programmed cell death) removes old, damaged, or mutated cells. Cancer cells evade apoptosis, allowing them to survive and multiply indefinitely.
• A NEOPLASM (tumor) is an abnormal mass of tissue resulting from uncontrolled cell division.
• Two critical gene families control cell growth: PROTO-ONCOGENES (promote normal growth) and TUMOR SUPPRESSOR GENES (brake cell division and trigger repair or death).
• When a proto-oncogene mutates, it becomes an ONCOGENE — like an accelerator stuck in the 'on' position, driving relentless proliferation.
• The most important tumor suppressor gene is P53, often called the 'guardian of the genome.' When p53 is mutated or lost, damaged cells escape repair and continue dividing.
• Cancer requires MULTIPLE mutations over time — it is not caused by a single event.

Definitions

Section Title

Normal Cell Regulation and How Cancer Develops

Common Mistakes

• Confusing proto-oncogenes (NORMAL, healthy) with oncogenes (MUTATED, cancer-promoting). Proto-oncogenes are not harmful until they mutate.
• Thinking that one mutation is enough to cause cancer — cancer requires multiple genetic changes over time (multistep process).
• Forgetting that cancer cells do NOT undergo normal apoptosis — this is why they accumulate and form tumors despite being damaged.

Exam Tips

• NLE scenario: 'A patient stopped smoking after 20 years. Which stage of carcinogenesis can still be halted by this action?' Answer: PROMOTION stage — because it is reversible.
• Memorize the carcinogen-cancer pairings: HPV = Cervical, Hep B/C = Liver, H. pylori = Gastric, EBV = Burkitt Lymphoma, UV radiation = Skin, Asbestos = Mesothelioma/Lung.
• Aflatoxin is a high-yield Philippine context item — link it to improper food storage and liver cancer risk in local communities.

Key Points

• Carcinogenesis is the process by which normal cells are transformed into cancer cells. It occurs in three sequential stages: INITIATION, PROMOTION, and PROGRESSION.
• INITIATION: A carcinogen causes an irreversible DNA mutation. The cell is permanently altered but does not yet proliferate abnormally. This change is IRREVERSIBLE.
• PROMOTION: Repeated exposure to promoting agents (tobacco, alcohol, chronic inflammation, hormones) causes the initiated cell to proliferate. This stage is REVERSIBLE — removal of the promoting agent can stop progression. THIS IS WHERE PREVENTION HAS THE GREATEST IMPACT.
• PROGRESSION: The tumor grows, develops its own blood supply (ANGIOGENESIS), becomes increasingly malignant, and acquires the ability to invade and metastasize. This stage is IRREVERSIBLE.
• CARCINOGENS are agents that cause the initiating DNA mutation. They are classified as: Chemical (tobacco, asbestos, benzene, aflatoxin from mold on peanuts and corn), Physical (ultraviolet radiation from the sun, ionizing radiation from X-rays), Infectious (HPV — cervical cancer; Hepatitis B and C — liver cancer; Epstein-Barr virus — Burkitt lymphoma; H. pylori bacterium — gastric cancer), and Hormonal/Genetic factors.
• AFLATOXIN is especially relevant in the Philippines — it is a chemical carcinogen produced by the mold Aspergillus flavus, found in improperly stored rice, corn, and peanuts, and is linked to liver cancer.
• The time between initiation and clinical cancer development can be YEARS TO DECADES — this is called the latency period.

Definitions

Section Title

Carcinogenesis: The Three-Step Process

Common Mistakes

• Mixing up which stage is REVERSIBLE and which is IRREVERSIBLE. KEY RULE: Initiation = irreversible. Promotion = REVERSIBLE (prevention works here). Progression = irreversible.
• Forgetting that H. pylori is a BACTERIAL carcinogen (not a virus) and is linked to GASTRIC (stomach) cancer, not liver cancer.
• Confusing HPV (cervical cancer) with Hepatitis B/C (liver cancer) — these are common NLE distractor items.

Exam Tips

• NLE TRAP ALERT: Melanoma ends in '-oma' but is MALIGNANT. Lymphoma ends in '-oma' but is MALIGNANT. Do not assume '-oma' = benign.
• Quick comparison table: Benign = SLOW, ENCAPSULATED, WELL-DIFFERENTIATED, NO metastasis. Malignant = FAST, INVASIVE, POORLY-DIFFERENTIATED, METASTASIZES.
• For tumor naming: 'carci-' comes from Greek for crab (karkinos) — malignant carcinomas spread with claw-like projections. Use this image to remember invasiveness.

Key Points

• BENIGN tumors grow slowly, are usually ENCAPSULATED (surrounded by a fibrous capsule), are WELL-DIFFERENTIATED (cells look like normal tissue), do NOT invade surrounding tissue, and do NOT metastasize. They rarely recur after surgical removal.
• MALIGNANT tumors grow rapidly, are NOT encapsulated, are POORLY DIFFERENTIATED or ANAPLASTIC (cells look very different from normal), INVADE surrounding tissue, and METASTASIZE to distant sites. They frequently recur.
• ANAPLASIA is the most extreme form of poor differentiation — the cells look so abnormal that the tissue of origin is difficult to identify. Anaplastic tumors are the most aggressive (Grade 4).
• NAMING CONVENTION: Benign tumors end in '-oma' (lipoma = benign fat tumor; fibroma = benign fibrous tissue tumor). Malignant tumors of EPITHELIAL tissue = CARCINOMA. Malignant tumors of CONNECTIVE TISSUE, MUSCLE, or BONE = SARCOMA. Blood-forming tissue cancers = LEUKEMIA. Lymph node/lymphatic tissue cancers = LYMPHOMA.
• A benign tumor CAN be life-threatening if it grows in a critical location — for example, a benign brain tumor (meningioma) can compress vital brain structures even though it does not metastasize.
• The most feared difference: MALIGNANT tumors METASTASIZE; BENIGN tumors do NOT.

Definitions

Section Title

Benign versus Malignant Tumors

Common Mistakes

• Thinking ALL '-oma' tumors are benign — EXCEPTIONS include melanoma (malignant skin cancer), hepatoma/hepatocellular carcinoma (malignant liver cancer), and lymphoma (malignant). These are classic NLE traps.
• Forgetting that a benign tumor CAN kill the patient — especially if located in the brain or spinal cord where it compresses vital structures.
• Confusing carcinoma (epithelial) with sarcoma (connective tissue) — remember 'C' for carcinoma = 'C'oating tissues (epithelium coats/lines organs).

Exam Tips

• Memorize metastatic sites: LLBB — Lungs, Liver, Bone, Brain. These are the four most common sites for cancer to spread.
• NLE scenario: 'A patient with breast cancer is found to have cancer in the liver. What type of cancer does the liver contain?' Answer: Metastatic breast cancer — NOT liver cancer.
• Lymphatic spread is most common for CARCINOMAS (epithelial cancers). Hematogenous spread is more common for SARCOMAS (connective tissue cancers).

Key Points

• METASTASIS is the spread of cancer cells from the PRIMARY (original) site to DISTANT organs. It is the defining feature of malignancy and the main reason cancer is life-threatening.
• Routes of metastatic spread: (1) DIRECT EXTENSION — tumor grows into immediately surrounding tissues. (2) LYMPHATIC spread — tumor cells enter lymph vessels and are carried to lymph nodes. This is the MOST COMMON route for CARCINOMAS. (3) HEMATOGENOUS spread — cells enter the bloodstream and travel to distant organs. More common for SARCOMAS. (4) TRANSCOELOMIC/CAVITY SEEDING — cells shed into a body cavity (e.g., peritoneal cavity in ovarian cancer) and implant on nearby organs.
• COMMON SITES OF METASTASIS: Lungs, Liver, Bone, and Brain. Memory aid: 'Lead Lung Left Bone Brain' or simply remember the 4 B's: Bone, Brain, Both-lungs, and Bowel (liver). In Philippine clinical practice, bone metastasis is commonly seen in breast and prostate cancer patients.
• CRITICAL CONCEPT: A metastatic tumor RETAINS THE CELL TYPE OF ITS PRIMARY ORIGIN. Example: If breast cancer spreads to bone, it is called 'metastatic breast cancer to bone' — NOT bone cancer. The treatment is directed at breast cancer, not bone cancer.
• Metastatic disease is classified as STAGE IV in the TNM staging system — the most advanced stage.
• Carcinoma in situ (Tis) = cancer cells are present BUT confined to the original layer of cells with NO invasion and NO metastasis. This is the earliest, most curable stage.

Definitions

Section Title

Invasion and Metastasis

Common Mistakes

• Stating that 'bone cancer' is present when breast cancer has spread to bone — this is METASTATIC BREAST CANCER, not primary bone cancer. The distinction affects treatment.
• Forgetting that the LYMPHATIC system is the most common route for CARCINOMA spread — lymph node assessment (sentinel node biopsy) is critical in breast cancer staging.
• Confusing carcinoma in situ (Stage 0, no invasion) with Stage 1 (early invasion present).

Exam Tips

• NLE strategy: When asked 'which symptom should a patient REPORT to their doctor immediately?', any symptom from CAUTION that has persisted is the answer.
• For community health teaching scenarios: Teach CAUTION to all adult patients as part of health promotion under the nursing role defined in RA 9173.
• Connect ABCDE to the 'O' in CAUTION — a wart or mole with ABCDE changes needs immediate evaluation (biopsy).

Key Points

• The American Cancer Society developed SEVEN warning signs of cancer summarized by the mnemonic CAUTION. Any sign that PERSISTS for more than 2 weeks should be evaluated by a health professional.
• C — CHANGE in bowel or bladder habits (persistent diarrhea, constipation, blood in stool or urine, changes in urine stream)
• A — A SORE that does not heal (especially in the mouth, skin, or genitals — think oral cancer, skin cancer)
• U — UNUSUAL bleeding or discharge (blood in sputum, urine, stool, abnormal vaginal bleeding, nipple discharge)
• T — THICKENING or a lump in the breast or elsewhere (palpable mass — breast cancer, testicular cancer, lymphoma)
• I — INDIGESTION or difficulty swallowing (dysphagia — think esophageal or gastric cancer)
• O — OBVIOUS change in a wart or mole (changes in size, color, shape — think melanoma; apply the ABCDE rule)
• N — NAGGING cough or hoarseness (persistent cough — think lung cancer; hoarseness — think laryngeal cancer)
• These are WARNING SIGNS, not diagnoses. A patient with these signs needs further evaluation. Definitive diagnosis requires BIOPSY.
• The ABCDE rule for moles/skin lesions: A = Asymmetry, B = Border irregularity, C = Color variation, D = Diameter >6 mm (larger than a pencil eraser), E = Evolving (changing over time).

Definitions

Section Title

Warning Signs of Cancer: The CAUTION Mnemonic

Common Mistakes

• Thinking CAUTION signs are diagnostic — they are WARNING SIGNS that require further evaluation, NOT a cancer diagnosis.
• Forgetting to include HOARSENESS under the 'N' (nagging cough or hoarseness) — hoarseness can indicate laryngeal or thyroid cancer.
• Missing that the 'I' in CAUTION includes DYSPHAGIA (difficulty swallowing), not just heartburn-type indigestion.

Exam Tips

• NLE quick rule: GRADE goes UP = cancer is MORE aggressive. STAGE goes UP = cancer has SPREAD MORE. Both being low = best outcome.
• M1 in the TNM system AUTOMATICALLY means Stage IV — the most advanced stage. Any NLE item with M1 = Stage IV = distant metastasis.
• Tis = 'in situ' = Stage 0 = confined = most curable. Link this to Pap smear screening detecting cervical intraepithelial neoplasia (CIN) at this stage.

Key Points

• GRADING and STAGING are two DIFFERENT systems. Never confuse them. GRADING = cellular level (how abnormal the cells look). STAGING = body level (how far the cancer has spread).
• GRADING (Differentiation): Grade 1 = Well differentiated, closely resembles normal tissue, LEAST aggressive. Grade 2 = Moderately differentiated. Grade 3 = Poorly differentiated. Grade 4 = Undifferentiated/ANAPLASTIC, bears no resemblance to normal tissue, MOST aggressive. RULE: Higher grade number = MORE aggressive = WORSE prognosis.
• STAGING uses the TNM System: T = Tumor (size and local extent), N = Nodes (regional lymph node involvement), M = Metastasis (presence of distant spread).
• T CATEGORIES: Tis = carcinoma in situ (no invasion). T1 = smallest/least invasive. T2, T3, T4 = increasing size and local invasion.
• N CATEGORIES: N0 = no lymph node involvement. N1, N2, N3 = increasing lymph node involvement.
• M CATEGORIES: M0 = no distant metastasis. M1 = distant metastasis PRESENT.
• OVERALL STAGE: Stage 0 (Tis, carcinoma in situ) → Stage I (small, localized) → Stage II (larger or slight nodal spread) → Stage III (significant nodal involvement) → Stage IV (M1, distant metastasis — most advanced). RULE: Lower stage number = earlier disease = better prognosis = more treatment options.
• M1 = Stage IV = distant metastasis = most advanced and most difficult to treat.
• Stage 0 (Tis) is the MOST CURABLE stage — cancer has not yet invaded beyond its layer of origin.

Definitions

Section Title

Tumor Grading and TNM Staging

Common Mistakes

• MOST COMMON MISTAKE: Confusing grading with staging. Remember: GRADE = cellular look (G1–G4 differentiation); STAGE = body spread (TNM, Stage 0–IV).
• Forgetting that HIGHER grade = WORSE (Grade 4 anaplastic = most aggressive), but LOWER stage = BETTER (Stage I = best prognosis).
• Confusing N0 (no node involvement — GOOD) with N1–N3 (node involvement — worse). 'N0' means NONE, which is favorable.

Exam Tips

• NLE question stem: 'Which test definitively confirms a cancer diagnosis?' Answer: BIOPSY — always.
• Tumor marker quick reference: PSA = Prostate; CA-125 = Ovarian; CEA = Colorectal (colon); AFP = Liver/Testicular. Memorize these pairs.
• Under RA 9173, health education is within the independent scope of nursing practice. Nurses can and should counsel on cancer prevention without a physician order.
• Philippine context: Connect HPV vaccine and Pap smear to CERVICAL CANCER — the 5th most common cancer in Filipino women — and relate it to DOH programs.

Key Points

• PRIMARY PREVENTION aims to PREVENT CANCER from developing by reducing or eliminating exposure to carcinogens. It addresses risk factors BEFORE cancer begins.
• Key primary prevention strategies: (1) TOBACCO CESSATION — the single most important modifiable risk factor, linked to lung, oral, esophageal, bladder, and other cancers. Counsel all patients on smoking cessation and avoidance of secondhand smoke. (2) LIMIT ALCOHOL — excess alcohol is linked to liver, oral, esophageal, and breast cancers. (3) SUN PROTECTION — sunscreen (SPF 30+), protective clothing, avoid peak UV hours (10 AM–4 PM). (4) HEALTHY DIET — high fiber, fruits, and vegetables; low in fat, salt-cured, smoked, and processed foods. (5) MAINTAIN HEALTHY WEIGHT and PHYSICAL ACTIVITY. (6) VACCINATION: HPV vaccine (prevents cervical, oropharyngeal, anal cancers) and HEPATITIS B VACCINE (prevents liver cancer). (7) OCCUPATIONAL SAFETY — limit exposure to asbestos, benzene, radiation.
• SECONDARY PREVENTION detects cancer EARLY when it is most treatable. Involves screening of apparently healthy, asymptomatic individuals.
• Key screening programs: BREAST — Monthly Breast Self-Examination (BSE), annual Clinical Breast Examination (CBE), MAMMOGRAPHY (recommended from age 40, high-risk from earlier). CERVICAL — PAP SMEAR (Papanicolaou test) starting at age 21 or within 3 years of first sexual activity; HPV co-testing from age 30. COLORECTAL — FECAL OCCULT BLOOD TEST (FOBT) annually; COLONOSCOPY every 10 years starting at age 45–50. PROSTATE — PSA blood test and DIGITAL RECTAL EXAMINATION (DRE) — decision made with patient after discussion. TESTICULAR — Monthly TESTICULAR SELF-EXAMINATION (TSE) in young men (ages 15–35). SKIN — Regular inspection using ABCDE rule.
• BIOPSY is the DEFINITIVE diagnostic test for cancer — the only way to confirm a cancer diagnosis histologically.
• TUMOR MARKERS are blood tests that detect substances produced by cancer cells: PSA (Prostate), CA-125 (Ovarian), CEA/carcinoembryonic antigen (Colorectal), AFP/Alpha-fetoprotein (Liver, Testicular). IMPORTANT: Tumor markers are primarily used to MONITOR TREATMENT RESPONSE and detect RECURRENCE — NOT for initial diagnosis alone.
• In Philippine community health nursing, nurses play a key role in promoting the DOH's cancer screening programs, particularly Pap smear clinics and breast cancer awareness campaigns in barangay health centers.

Definitions

Section Title

Primary and Secondary Prevention of Cancer

Common Mistakes

• Stating that tumor markers 'diagnose' cancer — they MONITOR treatment and detect RECURRENCE, but are NOT diagnostic tools on their own. Biopsy confirms diagnosis.
• Forgetting that the HPV VACCINE is PRIMARY prevention (prevents infection before cancer develops) — not secondary prevention.
• Confusing breast SELF-examination (monthly, by the patient) with CLINICAL breast examination (done by a healthcare provider) and MAMMOGRAPHY (imaging). All three are different screening levels.

Exam Tips

• NLE Philippine context: 'Most common cancer in Filipino women' = BREAST CANCER. 'Leading cause of cancer death in Filipino men' = LUNG CANCER. These are frequently tested.
• RA 11215 = NICCA = 2019 = Cancer Control Act. Associate '11215' with cancer the way you associate '9173' with nursing practice.
• For NLE items on nursing advocacy and patient education: Reference both RA 9173 (nursing duty to educate) and RA 11215 (government's cancer program) to anchor your answers.

Key Points

• Cancer is a LEADING CAUSE OF DEATH in the Philippines, ranking in the top causes of mortality alongside cardiovascular disease.
• LEADING CANCERS IN THE PHILIPPINES (high-yield for NLE): (1) BREAST CANCER — most common cancer OVERALL and the leading cancer among Filipino WOMEN. (2) LUNG CANCER — strongly linked to smoking; leading cause of cancer DEATH in MEN. (3) COLORECTAL CANCER (4) LIVER CANCER — associated with Hepatitis B (highly prevalent in the Philippines) (5) CERVICAL CANCER — associated with HPV (6) PROSTATE CANCER.
• The DEPARTMENT OF HEALTH (DOH) leads the national cancer response in the Philippines.
• REPUBLIC ACT NO. 11215 — the NATIONAL INTEGRATED CANCER CONTROL ACT (NICCA) of 2019 — established a comprehensive national cancer control program covering: Prevention, Early detection (screening), Diagnosis, Treatment, Palliation, Survivorship support, Financial protection for patients (Cancer Assistance Fund).
• NICCA created the CANCER ASSISTANCE FUND to help poor Filipino patients access cancer treatment — an important social protection mechanism nurses should know for patient advocacy.
• Nurses contribute to NICCA goals through: Community health education on modifiable cancer risk factors, Promotion of HPV and Hepatitis B vaccines, Smoking-cessation counseling, Facilitating access to DOH screening programs and cancer services.
• CULTURAL CONSIDERATIONS: Many Filipino patients and families hold fatalistic beliefs ('bahala na') about cancer — the nurse must address these beliefs with empathy and provide factual education that cancer IS preventable and early-stage cancer IS treatable.
• FAMILY-CENTERED CARE: Filipino culture places the family at the center of health decisions. Involve the family in health education and support — especially the spouse and immediate relatives who influence the patient's decision to seek care.

Definitions

Section Title

Cancer in the Philippines and RA 11215 (NICCA)

Common Mistakes

• Confusing RA 11215 (NICCA — cancer control) with RA 9173 (Philippine Nursing Act of 2002) — these are completely different laws. RA 9173 governs nursing practice; RA 11215 governs cancer control.
• Forgetting that BREAST CANCER is the number one cancer in the Philippines overall — not lung cancer. Lung cancer is the leading cause of cancer DEATH in Filipino men.
• Underestimating the role of Hepatitis B in LIVER CANCER in the Philippines — Hep B is endemic in the Philippines, making liver cancer a significant public health problem.

Exam Tips

• NLE prioritization: Always apply Maslow — physiological first, then safety (anxiety/fear), then psychosocial. For a patient in respiratory distress from lung cancer, address airway FIRST before anxiety.
• For NLE questions on patient teaching effectiveness: The BEST indicator that teaching was effective is the patient DEMONSTRATING the skill or RETURNING THE DEMONSTRATION (e.g., correctly showing BSE technique).
• RA 9173 scope: Health education is an INDEPENDENT nursing function. Nurses do not need a physician's order to teach cancer prevention — this may appear in NLE items on scope of practice.

Key Points

• NURSING ASSESSMENT includes: Thorough health history (risk factors — tobacco use, family history, occupational exposures, HPV/Hepatitis B vaccination status), Physical assessment for CAUTION warning signs, and Psychosocial assessment (fear, anxiety, denial, cultural beliefs).
• PRIORITY NURSING DIAGNOSES (NANDA) for cancer patients: (1) ANXIETY related to new cancer diagnosis and uncertain prognosis (Maslow — Safety and Security needs). (2) DEFICIENT KNOWLEDGE related to cancer risk factors, screening, and treatment options. (3) FEAR related to diagnosis, treatment, and death. (4) ANTICIPATORY GRIEVING related to potential loss of health/life. (5) INEFFECTIVE HEALTH MAINTENANCE related to lack of knowledge about cancer prevention and screening.
• MASLOW'S HIERARCHY in cancer prioritization: Physiological needs (pain, nutrition, airway) are addressed first, followed by Safety needs (anxiety, fear of diagnosis), then Love/Belonging (family support), then Esteem (body image changes), and Self-actualization (finding meaning in illness).
• DIAGNOSTIC WORKUP nursing responsibilities: Prepare the patient for biopsy (most definitive test) — explain the procedure, obtain informed consent, provide post-procedure care. Prepare for imaging studies (CT scan, MRI, PET scan, X-ray, ultrasound). Collect specimens for tumor marker testing. Explain findings in patient-understandable language.
• PATIENT AND FAMILY EDUCATION (key teaching points): Cancer is often PREVENTABLE. Early-stage cancer is frequently CURABLE. Report CAUTION signs that persist. Follow recommended SCREENING schedules. Adopt protective LIFESTYLE HABITS: no tobacco, limit alcohol, sun protection, healthy diet, regular exercise, recommended vaccines (HPV, Hepatitis B). Keep all FOLLOW-UP appointments.
• CULTURAL COMPETENCE in the Philippine setting: Acknowledge Filipino fatalistic tendencies about cancer with empathy. Use culturally appropriate language. Involve family members in education. Emphasize success stories of early detection and cure to counter fatalism. Connect patients to DOH programs and Cancer Assistance Fund (RA 11215).
• Under RA 9173, nurses are legally authorized and obligated to provide health education as an INDEPENDENT nursing function — this includes cancer prevention counseling without requiring a physician's order.

Definitions

Section Title

Nursing Management in Oncology: Assessment, Diagnosis, and Education

Common Mistakes

• Prioritizing psychosocial nursing diagnoses (anxiety, fear) over physiological ones — always address PHYSIOLOGICAL needs (airway, pain, nutrition) first per Maslow's framework.
• Forgetting that informed consent for biopsy is the physician's responsibility to obtain — the nurse's role is to WITNESS the signature and REINFORCE (not re-explain) the information provided.
• Providing false reassurance ('Don't worry, you'll be fine') to cancer patients — this is non-therapeutic. Instead, acknowledge feelings and provide factual support.