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Course: Oncology Nursing

Topic: Cancer Biology

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Describe the concepts of normal and cancer cellular growth, proliferation, differentiation and regulatory mechanisms.
Define the characteristics of benign and malignant cells and tumors.
Recognise the genetic, immunological, and hormonal basis of cancer.
Describe processes of invasion and metastases.
List common classification systems for cancer.
Compare and contrast common methods for diagnosing, staging and grading cancer.

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Introduction

The cell is the functional unit of life which helps in performing all the processes of life
All the organs in the body consist of specialized cells that carry out its functions (transportation of oxygen, digestion of nutrition, excretion of waste material, reproduction)
Worn out or injured cells must be replaced to assure the proper function of organs

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Normal Cell Growth and Development

There are two important cellular processes to balance cell growth:

Proliferation

Refers to growth and reproduction of cells

Apoptosis (Cell Death)

The process by which old or damaged cells are self destructed
For both normal and cancerous cells to be proliferated, they must undergo the process of cell division

The Cell Cycle has two phases

Mitosis (cell produces two identical daughter cells)
Interphase (period when cells carry its normal growth and metabolic activities: The cell grows and the DNA is duplicated)

Winchester Hospital, 2021

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Normal Cell Division vs Cancer Cell Division

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Critical Thinking Question

Normal cells typically only divide a limited number of times before programmed cell death occurs. However, cancer cells do not have the ability to initiate death via _____________________ and may divide indefinitely.

Mitotic Catastrophe
Apoptosis
Spindle Chaos
Evasion

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Normal Cell Differentiation

Cell Differentiation is a process by which a cell changes its structure to perform its specific function.
Two Types:

Poorly differentiated cells (Stem cells) are capable of new functions (For example, after trauma, stem cells provide a pool of cells that differentiate into specific cell types and repair tissue).
Well differentiated cells are mature and fully developed cells responsible for a particular function.

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Difference between Normal Cells and Cancer Cells

Normal Cells:

Grow in a controlled manner
Are more specialized
Mature into distinct cell types with specific functions
Follow signals to stop dividing when needed

National Cancer Institute, 2015

Cancer Cells:

Grow in uncontrolled manner
Less specialized
Cells do not mature into distinct types with specific functions
Do not follow the signal to stop dividing or to begin a process called apoptosis where the body gets rid of unneeded cells
This is because the cancer cells are also called the “break all the rules”

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Critical Thinking Question

Which of the following is true about cancer cells? (Select all that apply)

Grow in an uncontrolled manner
More specialized
Less specialized
Cells develop into a distinct type

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Characteristics of Tumors

A tumor is a mass of abnormally dividing cells
Types of tumors:

A. Benign (Non-cancerous tumor)

Composed of cells that do not invade surrounding tissue(s) or organ(s) but it may continue to grow in size abnormally
Well defined and grow slowly
Relatively easy to remove by surgery

Winchester Hospital, 2015

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Characteristics of Tumor

B. Malignant (Cancerous tumor)

Composed of cells that invade the basement membrane and spread to other parts of the body
Spread to different sites through blood or lymphatic system
Can not be removed through surgery
Needs advanced therapy e.g. chemotherapy and/or radiation therapy

Winchester Hospital, 2015

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Characteristics of Benign and Malignant Tumor

Babal and Câtoi, 2007

Characteristics/ Tumors	Benign	Malignant
Growth type	Expansive	Infiltrating
Growth speed	Slow (in general)	Rapid (in general)
Stabilization	Frequent	Exceptional
Structure	Typical	Atypical (Differentiation-anaplasia)
Mitoses	Rare and Typical	Numerous and Atypical
Evolution	Local	Local + General
Metastasizing	No	Yes
Local Consequences	Variable, Compression	Severe (Infiltration, necrosis)
General consequences	No	Constant + Severe
Spontaneous evolution	Usually Favorable	Always Fatal
Evolution after removal	No recurrences	Common recurrence

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Benign vs. Malignant Tumor

Characteristics of Tumor

Benign vs. Malignant Tumor

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Genetics and Cancer

Abnormal cell division occurs due to:

Presence of active oncogene
Absence of suppressor genes

How cells become abnormal:

When a part of the gene is deleted
Translocation (a chromosome is rearranged and ends up in the wrong place)
An extremely small defect in the DNA, resulting in an abnormal DNA "blueprint" and production of a defective protein

Cell contains a cancer-producing virus

National Cancer Institute, 2021

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Genetics and Cancer

Genes Mutation occurs in the cancer cells and causing them to become defective.
Two types of Mutation:

A. Dominant Mutation:

Abnormality in one gene pair.
A mutated gene that produces a defective protein that causes the growth-factor receptor on a cell's surface to be constantly "on" when, in fact, no growth factor is present.
The result is that the cell receives a constant message to divide. This dominant "gain of function gene" is often called an oncogene.

National Cancer Institute, 2021

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Genetics and Cancer

B. Recessive Mutation:

Is characterized by both genes damaged in the pair.
For example, a normal gene called p53 produces a protein that turns the cell cycle "off" thus, assisting with the control of cell growth. It is called an anti-oncogene or tumor suppressor gene.
If there is mutation in one p53 gene in the pair, the other gene is able to control the cell cycle but if there is mutation in both genes, the "off" switch is lost, and the cell division is no longer under control.

National Cancer Institute, 2021

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Immunity and Cancers

The immune system is responsible to fight against foreign invaders, and plays similar roles in protecting body from malignancy
The damaged DNA in cancer cells frequently direct the mutated cell to produce abnormal proteins known as tumour antigens that mark cancer cells as 'non-self'
In order to avoid an attack by the immune system, tumour cells use a range of strategies:

Such as suppression of expression of tumour-associated antigens or of MHC class 1 molecules, or even counterattack against immune cells

Australian Government, Cancer Australia, 2021

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Hormones and Cancers

Hormones are natural substances secreted by specialized cells and circulated in the blood throughout the body.
Growth and development of tissues throughout the body occurs under the influence of hormones.
Excessive hormonal stimulation of cell proliferation increases the risk of mutation and subsequent proliferation of mutated cell clones.
Therefore, Hormones are capable of acting as strong carcinogens.

Australian Government Cancer Australia, 2021

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Critical Thinking Question

Mr Rai has Rhabdomyosarcoma. What could be the possible causes of his condition? (Select all that apply)

Presence of an oncogene
Absence of suppressor oncogene
Some part of the gene is deleted
Presence of some virus

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Risk Factors

National Cancer Institute, 2021

Major risk factors for cancer:

Diet:

High fat diet (prostate cancer, endometrium, colon rectum)
Excess fat is involved in the production of free radicals which causes many types of cancer
Pickled, cured and smoked product due to nitrites

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Major Risk Factors (continued)

Smoking:

Causes the majority of lung cancers ( in smokers and those exposed to secondhand smoke)
The risk increases with the number of cigarettes smoked each day and the number of years smoked
Quitting at any age significantly lowers the risk of developing lung cancer

Areas affected: Lungs, Larynx, Oral Cavity

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Risk Factors

Genetics

Abnormal inherited genes
Genes are damaged by carcinogens, viruses, and errors in cell division

Occupation and Environment

Contact to carcinogens in work environment
Skin Cancer and exposure to ultraviolet rays

Infectious Agents

Epstein Barr virus - Burkitt's Lymphoma in children
Hepatitis B - Liver Cancer

National Cancer Institute, 2021

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Process of Invasion and Metastasis

The spread of cancer cells to the distant sites in the body through the bloodstream or lymphatics is called metastasis.

The metastatic cascade has three main processes:

1. Invasion:

Loss in cell adhesion capacity that allows malignant tumor cells to dissociate from the primary tumor mass.
Changes in cell-matrix interaction enables the cells to invade the surrounding stroma.

Martin, 2013

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Process of Invasion and Metastasis (continued)

2. Intravasation

The blood vessel within the tumor can provide a route for the detached cells to enter the circulatory system and lymphatic vessels, causing transportation of tumor cells to distant sites.

3. Extravasation

Escape of cancer cells from circulation
In the process of extravasation, cancer cells interact with the endothelial cells of local tissues and develop adhesion to the endothelial cells and form stronger bonds. Thus, penetrating the endothelium and the basement membrane.

Martin, 2013

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Process of Invasion and Metastasis

The metastasis cascade includes:

Acquisition of local invasiveness
Invasion of the cell into blood/lymph vessels (intravasation)
Transport through the blood/lymph vessels to distant tissue sites
Escape of the cancer cells from circulation (extravasation)
Ability to adapt to the local tissue environment and to proliferate

Cancer Council Australia, 2014

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Process of Invasion and Metastasis

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Common Classification of Cancer

National Cancer Institute, 2021

Cancer is commonly classified by:

1. The primary site of origin

According to the site of origin of cancer cell.
Examples: Lung cancer, breast cancer renal cell carcinoma, brain cancer etc.

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Common Classification of Cancer

National Cancer Institute, 2021

2. Histological or Tissue Types

According to International Classification of Diseases for Oncology, Third Edition (ICD-O-3) based on Tissue Types cancer has six major categories

Carcinoma
Sarcoma
Myeloma
Leukemia
Lymphoma
Mixed type

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Common Classification of Cancer

I. Carcinoma:

Refers to malignant neoplasm of epithelial cells present in internal and external lining of the body.

Example: Present in the skin, Gastrointestinal tract

Two major Subtypes:

Adenocarcinoma (Occurs in mucus membrane)
Squamous cell Carcinoma (Many areas of body)

Affects organs and glands that are capable of secretion.

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Common Classification of Cancer

II. Sarcoma:

Cancer that originates in supportive and connective tissue.

Example: Bones, muscles, tendons, cartilage.

Most common sarcomas develop as painful masses on the bone:

Rhabdomyosarcoma and Fibrosarcoma.

III. Myeloma:

Originates in the plasma cells of bone marrow.

IV. Leukemia:

Bone marrow cancer causing overproduction of immature white blood cells.

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Common Classification of Cancer

V. Lymphoma:

Cancer develops in the nodes and glands of the lymphatic system.

Examples: Spleen, tonsils, thymus.
Subclassified into two categories:

Hodgkin's Lymphoma.
Non-Hodgkin’s Lymphoma.

VI. Mixed Type:

Components are from both one category or differents categories.

Example: Adenosquamous carcinoma, Carcinosarcoma.

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Classification of Cancer by Grade

According to the WHO system, cancer is classified by:

Cytological features (e.g., extent of cellular differentiation and presence of dysplasia)
Morphological–structural observations (e.g., mitotic count and necrosis)

The grade is expressed numerically, generally from a low grade of 1, indicating a high level of cellular differentiation, to a high grade of 3 (poorly differentiated or undifferentiated)
Increasing abnormality increases the grade, from 1–4

Carbone, 2020

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Classification of Cancer by Grade

In general, tumors are graded as 1, 2, 3, or 4, depending on the amount of abnormality.
The following system is generally used:

GX: Grade cannot be assessed (undetermined grade)
G1: Well differentiated (low grade)
G2: Moderately differentiated (intermediate grade)
G3: Poorly differentiated (high grade)
G4: Undifferentiated (high grade)

National Cancer Institute, 2013

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Classification of Cancer by Stage

The most commonly used method for classification is TNM staging:

Tumor size (T)
Degree of regional spread or node involvement (N)
Distant metastasis (M)

TNM staging classification includes:

Stage 0: indicates cancer being in situ or limited to surface cells while
Stage I: indicates cancer being limited to the tissue of origin
Stage II: indicates limited local spread
Stage III: indicates extensive local and regional spread
Stage IV: is advanced cancer with distant spread and metastasis

National Cancer Institute, 2015

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TNM Staging of Cancer

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Critical Thinking Question

Name: Miss Sharma

Form of Cancer: Basal Cell Carcinoma

She visited an Oncology hospital and was diagnosed with Stage IV Carcinoma according to the TNM stage classification System. What does this mean?

Cancer being in situ or limited to surface cells
Cancer being limited to the tissue of origin
Indicates limited local spread
Advanced cancer with distant spread and metastasis

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Diagnosis of Cancer

Personal and family medical history
Physical exam

Palpable mass
Organomegaly

Lab Test

Blood (CBC, WBC)
Urine
Other body fluids

Tumor Markers: (Acid Phosphate, Alpha- Fetoprotein)
Imaging test (CT Scan,MRI, PET Scan, Ultrasounds)
Biopsy

National Cancer Institute, 2019

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References

Australian Government Cancer Council Australia, 2021. EdCan Learning Resources of Nurses. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/biol o gy-of-cancer/defining-cancer/immune-system

Baba & Câtoi (2007) Tumor Cell Morphology. The Publishing House of the Romania Academy. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK9553/

Baba AI, Câtoi C. Comparative Oncology. Bucharest (RO): The Publishing House of the Romanian Academy; 2007. Chapter 3, TUMOR CELL MORPHOLOGY. Available from: https://www.ncbi.nlm.nih.gov/books/NBK9553/

Bommer, U, Dr Kara L Perrow (nee Vine) PhD, Cancer Council Australia Oncology Education Committee. Cancer Biology: Molecular and genetic basis. Retrieved from: https://wiki.cancer.org.au/oncologyformedicalstudents/Cancer_biology:_Molecular_and_genetic_basis

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References

Carbone, A. (2020) Cancer Classification at the Crossroads. Cancers, 12(4), 980. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226085/

Martin TA, Ye L, Sanders AJ, et al. Cancer Invasion and Metastasis: Molecular and Cellular Perspective. In: Madame Curie Bioscience Database [Internet]. Austin (TX): Landes Bioscience; 2000-2013. Available from: https://www.ncbi.nlm.nih.gov/books/NBK164700/

National Cancer Institute (2015). About Cancer: Difference between normal cells and cancer cells. Retrieved from: https://www.cancer.gov/about-cancer/understanding/what-is-cancer#:~:text=Cancer%20is%20a%20disease%20caused,are%20also%20called%20genetic%20changes

Contact info: info@nursesinternational.org

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References

National Cancer Institute (n.d.). Registration and Surveillance Modules: Cell Biology of Cancer.. Retrieved from:

https://training.seer.cancer.gov/disease/cancer/biology/

National Cancer Institute (2015). About Cancer: Cancer Staging. Retrieved from:

https://www.cancer.gov/about-cancer/diagnosis-staging/staging

National Cancer Institute (2019). About Cancer: How Cancer is Diagnosed. Retrieved from: https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis

Contact info: info@nursesinternational.org

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References

National Cancer Institute SEER Training Module (2021). Registration and Surveillance Modules: Cancer Classification. Retrieved from:

https://training.seer.cancer.gov/disease/categories/classification.html

Winchester Hospital (2015). Health Library: Noncancerous Versus Cancerous Tumors. Retrieved from:

https://www.winchesterhospital.org/health-library/article?id=36488

Winchester Hospital (2015). Health Library: Normal Cell Growth and Development. Retrieved from:

https://www.winchesterhospital.org/health-library/article?id=36702‌

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