Oncology Nursing

Cancer Pathophysiology

Cellular Basis of Cancer

Cancer is a group of diseases characterized by uncontrolled cell growth, invasion, and metastasis
Hallmarks of cancer (Hanahan & Weinberg): sustained proliferative signaling, evading growth suppressors, resisting cell death, replicative immortality, inducing angiogenesis, activating invasion/metastasis, immune evasion, reprogramming metabolism
Genetics: oncogenes (gain-of-function, e.g., HER2, RAS, MYC), tumor suppressor genes (loss-of-function, e.g., p53, RB, BRCA1/2), mismatch repair genes (e.g., MLH1, MSH2)
Carcinogens: chemical (tobacco, asbestos, benzene), physical (UV radiation, ionizing radiation), biologic (HPV, HBV, EBV, H. pylori, HHV-8)
Initiation (DNA damage) → Promotion (clonal expansion) → Progression (invasiveness & metastasis)

Staging — TNM System

Component	Description
T — Primary Tumor	T0 = no evidence; Tis = carcinoma in situ; T1–4 = increasing size/local extension
N — Regional Lymph Nodes	N0 = no regional node involvement; N1–3 = increasing nodal involvement
M — Distant Metastasis	M0 = no distant metastasis; M1 = distant metastasis present

Stage grouping (0–IV): Stage 0 = Tis; Stage I = localized; Stage II–III = regional spread; Stage IV = distant metastasis
Grading: cellular differentiation. G1 (well-differentiated) → G4 (undifferentiated, poor prognosis)

Clinical Pearl: TNM is used for solid tumors. Hematologic malignancies (leukemia, lymphoma, myeloma) use different staging systems (e.g., Ann Arbor for Hodgkin's, Rai/Binet for CLL, IPI for NHL). Carcinoma in situ (Tis) = pre-invasive, stage 0 — excellent prognosis.

Treatment Modalities

Surgery

Curative: removes all visible tumor (wide local excision, radical resection, en bloc resection)
Prophylactic: removes tissue at high risk of malignancy (e.g., BRCA+ mastectomy, colectomy for FAP)
Palliative: relieves symptoms without cure (debulking, bypass, stenting, colostomy)
Diagnostic: biopsy (excisional, incisional, core needle, FNA), sentinel lymph node biopsy
Reconstructive: restores form/function after cancer resection (e.g., TRAM flap after mastectomy)
Nursing: pre-op teaching for expected changes (ostomy, mastectomy, altered body image); post-op monitoring for bleeding, infection, pain, DVT, ileus, wound healing

Chemotherapy

Drug Classifications

Class	Mechanism	Examples	Key Side Effects
Alkylating agents	Crosslink DNA; cell cycle nonspecific	Cyclophosphamide, cisplatin, carboplatin, busulfan	Myelosuppression, nausea/vomiting, hemorrhagic cystitis (cyclophosphamide — need hydration + mesna), nephrotoxicity (cisplatin), ototoxicity
Antimetabolites	Inhibit DNA/RNA synthesis; S-phase specific	Methotrexate, 5-FU, capecitabine, gemcitabine, cytarabine, pemetrexed	Mucositis (MTX, 5-FU), myelosuppression, hepatotoxicity, hand-foot syndrome (capecitabine, 5-FU), nephrotoxicity (MTX — need leucovorin rescue)
Anthracyclines	Intercalate DNA, inhibit topoisomerase II	Doxorubicin (Adriamycin), daunorubicin, epirubicin, idarubicin	Cardiotoxicity! (cumulative, dose-limited — maximum doxorubicin 450–550 mg/m²), myelosuppression, red urine (not hematuria), mucositis, alopecia
Topoisomerase inhibitors	Prevent DNA uncoiling	Topo I: irinotecan, topotecan. Topo II: etoposide	Myelosuppression, diarrhea (irinotecan — delayed, severe), mucositis, alopecia
Mitotic inhibitors (taxanes, vinca)	Disrupt microtubule function (M-phase)	Paclitaxel, docetaxel, vincristine, vinblastine, vinorelbine	Neurotoxicity (peripheral neuropathy — vinca alkaloids & taxanes), hypersensitivity reactions (taxanes — premedicate!), extravasation risk (vesicants!), myelosuppression
Platinum agents	Form DNA cross-links	Cisplatin, carboplatin, oxaliplatin	Nephrotoxicity (cisplatin — pre-hydrate!), ototoxicity, peripheral neuropathy (oxaliplatin — cold sensitivity), myelosuppression (carboplatin more than cisplatin)

Safe Handling & Administration

⚠ SAFETY ALERT — Chemotherapy Administration:

Two nurse verification of all chemo orders — five rights PLUS: dose calculation, route, infusion rate, patient ID (two identifiers), informed consent, and correct drug/regimen
Use PPE: chemo-resistant gloves, gown, eye protection. Preparation in Class II biosafety cabinet only (pharmacy).
Vesicants (doxorubicin, vincristine, paclitaxel, vinblastine): cause severe tissue damage if extravasated. Give via central line if possible. If peripheral, verify blood return frequently. Extravasation: stop infusion, aspirate drug, apply hot or cold (varies by drug), admin antidote (dexrazoxane for doxorubicin; hyaluronidase for vinca alkaloids; sodium thiosulfate for cisplatin)
Waste disposal: chemotherapy-specific waste containers. Spill kit available.
Pregnant nurses should not handle chemotherapy.

Radiation Therapy

Type	Description	Nursing Care
External Beam (EBRT)	Linear accelerator delivers focused radiation from outside the body. Fractionated (daily doses for several weeks). Fields may be marked with permanent ink or tattoos.	Protect skin in treatment field: no creams, lotions, perfumes, deodorant (unless approved); use mild soap + water; loose cotton clothing; avoid sun exposure. Fatigue is universal. Monitor for dermatitis, erythema, desquamation, burns
Brachytherapy (Internal)	Radioactive source placed inside body: intracavitary (e.g., cervix, vagina), interstitial (e.g., prostate, breast), intraluminal (e.g., esophagus, bronchus)	Patient emits radiation! Private room; limit visitors (≤ 15–30 min/day, stay 6+ feet); no pregnant visitors/children. Nursing: time-limited care, use lead shielding, dosimeter badge. High-dose-rate (temporary — removed after treatment) vs. low-dose-rate (permanent seeds, e.g., prostate I-125)
Systemic (Radiopharmaceuticals)	Radioactive isotopes given PO/IV (e.g., I-131 for thyroid, Ra-223 for bone metastases, Lu-177)	Radioactive precautions per isotope (I-131: private room, separate bathroom, no sharing utensils, sleep alone; patient's saliva/urine/swear are radioactive). Emphasize hand hygiene, flush toilet twice. Duration depends on isotope half-life

Common side effects by site: Skin (dermatitis, erythema, desquamation, fibrosis); Oral mucosa (mucositis, xerostomia — head/neck); Esophagus (esophagitis, dysphagia); Lung (pneumonitis, fibrosis); Abdomen (nausea, diarrhea, proctitis); Pelvis (cystitis, proctitis, infertility, vaginal stenosis)
Nursing: Assess skin daily, manage fatigue (energy conservation, exercise), nutritional support, dysphagia management, lymphedema precautions (after axillary/inguinal RT), patient/family education

Immunotherapy

Harnesses the immune system to fight cancer; several categories:
Checkpoint inhibitors (ICIs): Block T-cell inhibitory pathways (PD-1/PD-L1, CTLA-4). Examples: pembrolizumab (Keytruda), nivolumab (Opdivo), ipilimumab (Yervoy), atezolizumab (Tecentriq)
Side effects — immune-related adverse events (irAEs):
- Dermatitis (rash, pruritus — most common)
- Colitis (diarrhea, abdominal pain)
- Hepatitis (↑ LFTs)
- Pneumonitis (cough, dyspnea — can be fatal)
- Endocrinopathies (hypothyroidism, adrenal insufficiency, hypophysitis, type 1 DM)
- Myocarditis, nephritis, arthritis, uveitis
Management: Corticosteroids for moderate-severe irAEs; hold immunotherapy; endocrine replacement as needed
CAR-T cell therapy: Patient's T cells engineered to express chimeric antigen receptor targeting cancer cells. Side effects: Cytokine Release Syndrome (CRS) — fever, hypotension, hypoxia; neurotoxicity (ICANS). Requires monitoring in specialized center

Hormonal Therapy

Used for hormone-sensitive tumors (breast, prostate, endometrial)
Breast cancer:
- Selective estrogen receptor modulators (SERMs): tamoxifen — blocks ER in breast. Side effects: hot flashes, DVT risk, endometrial cancer risk
- Aromatase inhibitors (AIs): anastrozole, letrozole, exemestane — ↓ estrogen in postmenopausal women. Side effects: arthralgias, osteoporosis, fractures
- GnRH agonists: leuprolide, goserelin — ovarian suppression in premenopausal
Prostate cancer:
- GnRH agonists: leuprolide, goserelin — testosterone suppression. Side effects: hot flashes, fatigue, osteoporosis, muscle loss, mood changes
- GnRH antagonists: degarelix
- Antiandrogens: bicalutamide, enzalutamide
- Abiraterone — inhibits androgen synthesis in adrenal glands/testes/prostate

Side Effect Management

Nausea & Vomiting (CINV)

Type	Timing	Management
Acute	< 24 hours after chemo	5-HT₃ antagonists (ondansetron, palonosetron) + dexamethasone ± NK₁ antagonist (aprepitant, fosaprepitant)
Delayed	24+ hours (especially cisplatin, cyclophosphamide)	Dexamethasone + metoclopramide or 5-HT₃ ± aprepitant. Days 2–4
Anticipatory	Before next cycle (Pavlovian conditioning)	Best prevented by controlling acute & delayed CINV; benzodiazepines (lorazepam), relaxation techniques
Breakthrough	Despite prophylaxis	Add agent from different class; prochlorperazine, haloperidol, olanzapine, dronabinol

Clinical Pearl: Chemotherapy emetogenic risk levels: High (> 90%) — cisplatin, cyclophosphamide ≥ 1500 mg/m², AC combination (doxorubicin + cyclophosphamide). Moderate (30–90%) — carboplatin, oxaliplatin, irinotecan, epirubicin. Low (10–30%) — paclitaxel, docetaxel, 5-FU, gemcitabine, methotrexate. Minimal (< 10%) — vincristine, bleomycin. Non-pharmacologic: acupressure, ginger, small bland meals, avoid strong odors.

Mucositis

Inflammation/ulceration of oral mucosa (and GI tract); common with 5-FU, methotrexate, doxorubicin, head/neck radiation
Assessment: daily oral assessment using WHO or NCI-CTCAE scale (grade 0–4); redness → patchy ulceration → confluent → inability to eat/drink
Prevention: good oral hygiene (soft toothbrush, non-alcohol mouthwash), cryotherapy (ice chips during 5-FU bolus — vasoconstriction reduces drug delivery to oral mucosa), palifermin (growth factor) for mucositis prophylaxis in some protocols
Treatment: "Magic mouthwash" (viscous lidocaine, Maalox, Benadryl ± nystatin); topical analgesics; oral care protocol (q4h); antifungal if candidiasis appears; IV hydration/nutrition if severe; pain management

Myelosuppression & Neutropenia

⚠ NEUTROPENIC PRECAUTIONS (ANC < 500):

Private room, private bathroom; strict hand hygiene for all
No fresh flowers, plants, or fresh fruits/vegetables (potential mold/bacteria)
No uncooked foods (raw meat, sushi, eggs); well-cooked foods only
Avoid rectal temps, suppositories, enemas, and rectal exams
No indwelling urinary catheters unless absolutely necessary
Take temperature at standard times and PRN; report fever immediately (> 100.4°F / 38.3°C = oncologic emergency!)
Monitor for subtle signs of infection — fever may be the ONLY sign, and often the first sign (no pus because no neutrophils)
Limit visitors and restrict those with illness; no children with recent live vaccines
Administer G-CSF (filgrastim / Neupogen or pegfilgrastim / Neulasta) as ordered to stimulate WBC production

WBC & ANC monitoring: Nadir (lowest point) varies by drug — typically 7–14 days after chemo. ANC = WBC × (% neutrophils + % bands) ÷ 100
G-CSF growth factors: Filgrastim (daily SQ/IV) or pegfilgrastim (single dose 24+ hours after chemo, not within 14 days of next cycle). Side effects: bone pain (common)

Anemia & Fatigue

Anemia (Hgb < 12 g/dL): pallor, weakness, dyspnea, fatigue, tachycardia, dizziness
Erythropoiesis-stimulating agents (ESAs: epoetin alfa, darbepoetin alfa) — used ONLY for chemotherapy-induced anemia (not for CKD or other causes). Target Hgb ~10–11 g/dL (do NOT exceed 12 g/dL — ↑ thrombosis risk and mortality). Assess iron stores (ferritin, transferrin sat) before starting
Blood transfusion: PRBCs if Hgb < 7–8 g/dL (symptomatic). Educate on energy conservation, fall prevention, nutritional support (iron, B₁₂, folate as appropriate)
Cancer-related fatigue (CRF): Most common side effect. Distinct from normal fatigue — not relieved by rest. Interventions: treat reversible causes (pain, depression, anemia, sleep disturbance, deconditioning), energy conservation, moderate exercise (shown to be effective!), nutrition, psychosocial support

Thrombocytopenia

Platelet count < 150,000: risk of bleeding increases as count drops. < 50,000 = bleeding with minor trauma; < 20,000 = spontaneous bleeding; < 10,000 = life-threatening (intracranial hemorrhage)
Bleeding precautions:
- Monitor for signs: petechiae, ecchymoses, epistaxis, gingival bleeding, hematuria, hematochezia, melena, vaginal bleeding, headache (possible ICH)
- Use soft-bristle toothbrush; avoid flossing
- Electric razor instead of blade
- Avoid IM injections if possible; if necessary, use smallest needle and hold pressure × 5+ minutes
- No rectal temps, suppositories, enemas
- Prevent falls and injury; pad side rails
- Avoid NSAIDs, aspirin, and anticoagulants
- Stool softeners to prevent straining
Platelet transfusion: for count < 10,000 (or < 20,000 with fever/bleeding/procedures). One unit typically raises count by 30,000–60,000

Alopecia

Hair thinning or complete loss; occurs 1–3 weeks after first dose; reversible on completion of treatment (regrowth may have different color/texture)
No proven prevention (scalp hypothermia/cold caps may reduce for taxanes, not for anthracyclines). Emotional support is critical — offer wig prescription, scarves, caps. "Hair loss will begin 1–3 weeks after your first treatment"

Pain

Types: Nociceptive (somatic — well-localized; visceral — dull, crampy) and Neuropathic (burning, shooting, tingling — from nerve compression/infiltration or chemotherapy-induced peripheral neuropathy — CIPN)
WHO Analgesic Ladder: Step 1 (non-opioid ± adjuvant) → Step 2 (weak opioid ± non-opioid ± adjuvant) → Step 3 (strong opioid ± non-opioid ± adjuvant)
Neuropathic pain: gabapentin, pregabalin, TCAs (nortriptyline, amitriptyline), duloxetine (first-line for CIPN)
Assess pain regularly (0–10 scale). Use scheduled + PRN dosing for cancer pain. Address constipation with opioids (bowel regimen = stimulant laxative + stool softener)

Oncologic Emergencies

Emergency	Pathophysiology	S/S	Nursing & Management
Superior Vena Cava (SVC) Syndrome	Tumor (usually lung cancer, lymphoma) compresses SVC → obstructs venous return from head/neck/upper extremities	Facial/neck/upper extremity edema (edema of "cape" area), distended neck/chest veins, dyspnea, cough, hoarseness, headache, dizziness, dilated collateral vessels on chest	Elevate HOB (reverse Trendelenburg); O₂; IV diuretics (cautiously); steroids (dexamethasone) to reduce tumor edema; radiation and/or stent placement for definitive treatment. Avoid arm/IV on same side; monitor for cerebral edema (↓ LOC, vision changes)
Tumor Lysis Syndrome (TLS)	Rapid tumor cell death (especially after chemo for highly proliferative tumors: leukemia, NHL, bulky solid tumors) → massive release of intracellular contents → hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia	Nausea, vomiting, muscle cramps, tetany, cardiac arrhythmias (peaked T → wide QRS → V-tach/V-fib), seizures, acute kidney injury, oliguria	Prevention is key! Aggressive hydration (3 L/m²/day IV), allopurinol (↓ uric acid production) or rasburicase (rapidly breaks down uric acid), frequent lab monitoring (K⁺, P, Ca²⁺, Uric acid, Cr q4–8h). Treatment of TLS: correct hyperkalemia (insulin + dextrose, albuterol, sodium polystyrene, calcium gluconate for cardiac protection if ECG changes), manage hyperphosphatemia (phosphate binders), treat hypocalcemia IF symptomatic. Hemodialysis if severe or refractory
Hypercalcemia of Malignancy	Bone metastases (breast, lung, multiple myeloma, prostate) → osteoclast activation → bone resorption → ↑ Ca²⁺. Also: paraneoplastic PTHrP secretion (squamous cell, renal, ovarian)	"Stones, bones, groans, psychiatric overtones" — Kidney stones, bone pain, abdominal pain/constipation, altered mental status, confusion, weakness, fatigue, polyuria, polydipsia, dehydration, shortened QT interval, bradycardia	IV isotonic hydration (NS, 200–500 mL/h) first; calcitonin (rapid onset but short lived); bisphosphonates (pamidronate, zoledronic acid — onset 24–48h); denosumab; loop diuretic (furosemide) AFTER hydration — NOT thiazides; treat underlying tumor; monitor for fluid overload (HF, renal impairment); fall prevention due to weakness/confusion
Spinal Cord Compression (SCC)	Metastatic tumor (breast, lung, prostate, multiple myeloma, lymphoma) in epidural space → cord compression. Often thoracic spine	EMA: (1) Epidural metastasis; (2) Motor weakness (lower extremity); (3) Autonomic dysfunction (bowel/bladder incontinence — LATE sign). Back pain is often the FIRST symptom (worse supine, worse with Valsalva/coughing). Sensory loss, ataxia	EMERGENCY! Time-sensitive — irreversible paralysis can occur within hours. High-dose IV corticosteroids (dexamethasone) STAT; MRI spine for diagnosis; radiation therapy and/or surgical decompression; log-roll for positioning; monitor for loss of bowel/bladder function; pain management; DVT prophylaxis
Febrile Neutropenia	ANC < 500 + single temperature ≥ 101°F (38.3°C) or sustained ≥ 100.4°F (38°C) for ≥ 1 hour	Fever may be the ONLY sign (no WBCs to form pus); may have rigors, malaise, signs of infection at port/line, oral/pharyngeal exam may reveal mucositis	EMERGENCY! Blood cultures (peripheral AND central line) × 2 sets; CBC with differential, UA, CXR, other cultures as indicated; broad-spectrum IV antibiotics within 1 hour (eg, cefepime, piperacillin-tazobactam, carbapenem ± vancomycin); G-CSF; monitor vitals q4h; neutropenic precautions; avoid rectal temps/procedures

Clinical Pearl: For oncologic emergencies, your key role is recognition and escalation. Know the early red flags: new back pain in a cancer patient = spinal cord compression until proven otherwise. Temp ≥ 100.4°F + recent chemo = febrile neutropenia. Facial swelling + dyspnea = SVC syndrome. Remember: Tumor Lysis Syndrome peaks 12–72 hours after chemotherapy initiation — this is when lab monitoring is most critical.

Palliative & Hospice Care / End-of-Life

Palliative vs. Hospice

Feature	Palliative Care	Hospice Care
Goal	Improve quality of life for any stage of illness; concurrent with curative treatment	Comfort and support at end of life; no curative treatment
Timing	Any time from diagnosis; appropriate alongside active treatment	Prognosis of ≤ 6 months (Medicare requirement); patient/family choose comfort measures only
Setting	Hospital, outpatient, home, long-term care	Home (most common), hospice facility, hospital, nursing home
Services	Symptom management, communication, care coordination, psychosocial/spiritual support	Comprehensive — nursing, home health aide, chaplain, social work, volunteer, bereavement counseling; 24/7 on-call; medications, equipment, supplies related to terminal diagnosis
Reimbursement	Standard insurance/Medicare Part B/Part D	Medicare Hospice Benefit (Part A): covers all hospice-related care — no copays for hospice services

End-of-Life Symptom Management

Symptom	Interventions
Pain	Around-the-clock opioid dosing (morphine, hydromorphone, fentanyl) + breakthrough PRN; titrate to effect; no upper dose limit in terminal illness; address constipation
Dyspnea	Opioids (morphine 2.5–5 mg PO/IV/SL q1h PRN — gold standard for dyspnea); O₂ for hypoxemia; fan (moving air reduces sensation of air hunger); elevate HOB; anxiolytics (lorazepam); position of comfort
Terminal Secretions ("Death Rattle")	Position side-lying; anticholinergics (scopolamine patch, glycopyrrolate, atropine drops); reduce IV fluids; gentle suction ONLY if ineffective cough; family education (this is not painful for the patient)
Nausea/Vomiting	Haloperidol, metoclopramide, ondansetron; scopolamine patch for bowel obstruction
Agitation / Terminal Restlessness	Haloperidol (first-line), lorazepam (especially if anxiety prominent), chlorpromazine; assess for reversible causes (pain, urinary retention, constipation); gentle reorientation; family presence
Delirium	Haloperidol (low dose); rule out reversible causes; calm environment; family education
Constipation	Stimulant laxative (senna) + stool softener (docusate) — scheduled, not PRN; osmotic laxatives (polyethylene glycol, lactulose); tap water enema if impaction
Xerostomia (Dry Mouth)	Frequent mouth care; ice chips; artificial saliva; oral swabs; lip balm
Anorexia / Cachexia	No artificial nutrition at end of life (does not improve comfort or survival); allow patient to choose what/when to eat; treat reversible causes (nausea, pain, constipation); family education on natural process

Nursing Care at End of Life

Physical care: meticulous skin care (immobility → pressure injuries); mouth care (q2h); bowel and bladder management; turn q2h; pain and symptom management
Psychosocial-spiritual care: presence; active listening; life review; dignity therapy; facilitate visits from clergy or spiritual care; cultural sensitivity; family presence
Family support: education on what to expect (signs of approaching death: ↓ LOC, Cheyne-Stokes respirations, mottling, ↓ urine output, loss of swallow, "death rattle"); encourage rest, eating, and self-care for caregivers; offer referral to bereavement counseling
Cultural considerations: vary widely — truth-telling, decision-making authority, rituals at death, post-mortem care preferences. Ask the patient/family about cultural preferences — do not assume

Clinical Pearl: The principle of double effect — giving opioids to relieve pain and dyspnea is ethically permissible even if it may (as a secondary, unintended effect) hasten death. The INTENT is symptom relief, not death. This is NOT euthanasia or physician-assisted suicide. Always document the indication and the symptom response.

NCLEX Prevention & Detection Education

Cancer Screening Recommendations

Cancer	Screening	Recommendation
Breast	Mammogram ± clinical breast exam	Age 40–44: optional; 45–54: yearly; ≥ 55: q2 years (USPSTF). High-risk (BRCA+): MRI + mammogram yearly beginning age 30
Cervical	Pap smear + HPV co-testing	Begin age 21; q3 years (Pap alone) or q5 years (Pap + HPV) to age 65. HPV vaccine for ages 9–26 (ideally 11–12)
Colorectal	Colonoscopy; FIT/FOBT; CT colonography	Begin age 45; colonoscopy q10 years; FIT yearly; CT q5 years. Earlier for family history, IBD
Lung	Low-dose CT chest	Annual for ages 50–80 with ≥ 20 pack-year smoking history + current smoker or quit within 15 years
Prostate	PSA ± DRE	Discuss shared decision-making at age 50 (45 for high-risk: African American, family history). Not routinely recommended for all
Skin	Full-body skin exam	Routine screening not recommended for average risk. High-risk: periodic skin exam. Teach ABCDEs of melanoma

Cancer Prevention Teaching

Tobacco cessation: #1 preventable cause of cancer (lung, head/neck, esophageal, bladder, pancreas, kidney, cervical, colorectal, and more). Discuss every visit; offer resources (1-800-QUIT-NOW, nicotine replacement, counseling)
Sun protection: SPF ≥ 30, broad-spectrum (UVA/UVB), reapply q2h; avoid tanning beds (class 1 carcinogen!); protective clothing; sunglasses; avoid peak sun 10 AM–4 PM
Diet & exercise: maintain healthy weight; plant-forward diet; limit red/processed meats; limit alcohol (< 1 drink/day women, < 2 men); fiber 25–30 g/day; 150 min moderate exercise/week
Vaccinations: HPV (9-valent) — prevents cervical, oropharyngeal, anal, vulvar, vaginal, penile cancers; HBV — prevents hepatocellular cancer. Recommended for children 11–12; catch-up through age 26
Environmental/occupational: avoid asbestos, benzene, radon (test homes!); safe handling of chemotherapy; proper PPE for radiation workers
Genetic risk: refer for genetic counseling if strong family history (multiple family members, early-onset cancers, multiple cancers in same person, known mutation). BRCA testing for high-risk breast/ovarian; Lynch syndrome testing for colorectal
Chemoprevention: tamoxifen/raloxifene for high-risk breast cancer; aspirin for colorectal (limited); finasteride for prostate (limited benefit)

Warning Signs — CAUTION mnemonic

Letter	Warning Sign
C	Change in bowel or bladder habits
A	A sore that does not heal
U	Unusual bleeding or discharge
T	Thickening or lump in breast or elsewhere
I	Indigestion or difficulty swallowing
O	Obvious change in wart or mole
N	Nagging cough or hoarseness

Clinical Pearl: As a nurse, you are the patient's first line of defense. Teach patients to know their bodies and report changes. Use the CAUTION mnemonic to remember warning signs. Reinforce: "Most cancers found early have better outcomes — screening saves lives."