This page covers Oncology Nursing Practice, 15% of the scored OCN questions: how cancer starts and spreads, how it is staged and graded, which tests read its genes, and the professional standards around the work. Safe handling of hazardous drugs is also part of this area, but it is taught with safe chemotherapy administration.
A competent patient with early-stage, curable lymphoma declines chemotherapy after a full discussion with the oncologist. What is the nurse's most appropriate action?
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An ethics consult addresses disagreement; it has no power to override an informed refusal by a patient with capacity.
Holding a patient to force a change of mind is coercion and is not permitted.
Recruiting family pressure undermines a capable patient's autonomy and the trust needed if the patient later reconsiders.
A competent adult may refuse even curative treatment; the nurse checks that the refusal is informed, documents it and keeps the door open to future care.
Biology & staging
A patient with chronic lymphocytic leukemia has a 17p deletion with a TP53 mutation. The nurse understands this finding predicts:
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FCR works poorly when TP53 is lost, so this finding argues against FCR.
Imatinib targets BCR-ABL1 in chronic myeloid leukemia and has no role in CLL.
Del(17p)/TP53 marks high-risk CLL; it does not by itself start treatment, but it signals aggressive behavior, not indolence.
Loss of TP53 function blunts the DNA-damage pathway that chemoimmunotherapy relies on, so these patients are steered to targeted agents such as BTK or BCL-2 inhibitors.
Biology & staging
A woman has a 3.2-cm breast tumor and biopsy-proven cancer in two movable ipsilateral axillary nodes; staging scans show no distant spread, and she has not had surgery. Her stage is classified as:
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Clinical N2 means fixed or matted axillary nodes or internal mammary nodes; two movable nodes are N1.
The p prefix needs a surgical specimen; she has not had surgery, so the stage is clinical.
A 3.2-cm tumor is T2 (over 2 cm up to 5 cm), movable ipsilateral level I–II nodes are N1, and staging before surgery carries the clinical prefix c.
T3 starts above 5 cm; this tumor is 3.2 cm.
Biology & staging
A patient's melanoma recurs 15 years after complete resection. Which phase of cancer immunoediting best explains the long dormant period?
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In equilibrium the immune system holds residual tumor cells in check without clearing them, which can keep disease dormant for years.
Initiation is the first, irreversible DNA damage in carcinogenesis, not a phase of immunoediting.
Escape is when the tumor finally evades control and grows, which describes the recurrence itself, not the quiet years before it.
Elimination is the phase in which immune cells destroy the tumor cells, which would leave nothing to recur.
Biology & staging
After surgery for medullary thyroid carcinoma, which tumor marker is used to watch for recurrence?
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Thyroglobulin comes from follicular cells and is the marker for papillary and follicular thyroid cancer, not medullary.
AFP is followed in liver cancer and nonseminomatous germ cell tumors.
CA-125 is used mainly in ovarian cancer.
Medullary carcinoma arises from parafollicular C cells, which secrete calcitonin, so calcitonin (with CEA) is followed after surgery.
Biology & staging
Which is the most common primary malignant brain tumor in adults?
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Primary CNS lymphoma is malignant but accounts for only a small share of adult brain tumors.
Glioblastoma, a grade 4 astrocytic tumor, is the most frequent malignant primary brain tumor in adults.
Meningioma is the most common primary brain tumor overall, but most are benign.
Medulloblastoma is a malignant tumor mostly of children, uncommon in adults.
Biology & staging
Which feature is characteristic of invasive lobular carcinoma of the breast?
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Most lobular cancers are hormone receptor-positive and HER2-negative.
Lobular carcinoma lacks the adhesion protein E-cadherin, so cells grow in single-file strands and the tumor is often hard to see on imaging.
Clustered calcifications are typical of ductal carcinoma in situ; lobular tumors often lack them.
Paget disease of the nipple is linked to underlying ductal carcinoma, not lobular carcinoma.
Biology & staging
A plasma ctDNA test in a 78-year-old patient with lung cancer reports a DNMT3A variant at a 1% allele frequency. What is the most likely source?
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DNMT3A variants at low allele fractions in an older adult usually come from expanding blood-cell clones that shed DNA into plasma, not from the tumor.
DNMT3A is not a lung cancer driver, and a 1% fraction in an older adult fits blood-cell clones better than tumor DNA.
A specific DNMT3A variant at low level in a 78-year-old has a well-known biological source, so contamination is not the likely explanation.
A germline variant appears at about 50% (or 100%) allele frequency, not 1%.
Biology & staging
A patient enrolled in a clinical trial says, 'I signed the consent, so I have to finish all the cycles.' What is the nurse's best response?
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No rule ends the right to stop once dosing has begun.
Trials plan for dropouts, and pressuring a participant to stay is coercive.
Research rules guarantee that a participant can stop at any point without losing the care or benefits otherwise due; signing consent does not lock a patient in.
Withdrawal is the participant's decision and needs no sponsor approval.
Biology & staging
Two men each have a Gleason score of 7 on prostate biopsy: one is 3 + 4 and the other 4 + 3. Which statement is accurate?
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Scores run up to 10 (5 + 5); 7 is intermediate.
The same total of 7 hides a real difference: the predominant pattern changes the grade group and risk.
The first number is the most common pattern; when pattern 4 predominates (Grade Group 3) the outlook is worse than when pattern 3 predominates (Grade Group 2).
The first number is the most common pattern; on a biopsy the second is the highest grade seen, so neither number alone marks the worst area.
Biology & staging
A patient with a refractory solid tumor and no standard options may receive pembrolizumab on a tumor-agnostic basis when testing shows:
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LDH is a general prognostic marker of tumor burden, not a biomarker for selecting immunotherapy.
KRAS G12C points to a KRAS G12C inhibitor in certain cancers, not to a pan-tumor checkpoint approval.
HER2 overexpression leads to HER2-directed drugs, not to pembrolizumab.
Pembrolizumab has a tumor-agnostic approval for solid tumors with high mutational burden (at least 10 mutations per megabase) that progressed on prior treatment, as it does for MSI-high or mismatch-repair-deficient tumors.
Biology & staging
A patient with a 30-pack-year history asks whether quitting smoking now still lowers cancer risk. Which stage of carcinogenesis can be reversed by removing the exposure?
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Promotion needs repeated exposure to promoters such as tobacco smoke; removing the exposure can halt or reverse it, which is why quitting still lowers risk.
Initiation is the first, permanent DNA damage; quitting cannot undo it.
Metastasis is spread of established cancer, not a stage that quitting reverses.
Progression is the irreversible step to a malignant, invasive clone.
Biology & staging
Follicular lymphoma often overexpresses BCL-2. How does this protein contribute to cancer?
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BCL-2 holds the mitochondrial death pathway closed, so damaged cells survive and accumulate; this is the target of venetoclax.
New vessel growth is driven mainly by VEGF signaling.
Telomerase activation allows endless division but is a separate mechanism from BCL-2.
Cell-cycle acceleration is driven by cyclins and CDKs, not by BCL-2.
Biology & staging
Why does the AJCC stage p16-positive (HPV-related) oropharyngeal cancer separately from p16-negative disease?
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Tobacco is the main cause of p16-negative disease; HPV-related cancer is often seen in people who never smoked.
HPV-driven oropharyngeal cancer has much better survival than tobacco-related disease, so AJCC (8th edition) gives it its own staging.
Distant spread is not more common; the separate staging reflects better outcomes.
HPV-related tumors are usually more sensitive to radiation and chemoradiation, not less.
Biology & staging
Chemotherapy is often given after surgical debulking of a bulky tumor. Which principle best explains this approach?
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The opposite happens: resting cells are recruited into the cycle as the mass shrinks.
Shrinking a tumor brings resting cells back into the cycle, so a larger share is dividing and is more sensitive to chemotherapy.
Removing bulk speeds up the growth of the remaining cells rather than slowing it, which is why they become easier to hit.
Growth speeds up as the tumor shrinks, so doubling time shortens.
Biology & staging
A biopsy of a liver metastasis from an unknown primary includes immunohistochemistry. The nurse explains that IHC is used to:
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Inherited variants are found by germline testing of blood or saliva, not by staining tumor proteins.
Circulating tumor cells are counted in a blood sample, not stained in a biopsy.
Stains for proteins such as cytokeratins or TTF-1 show the tissue a metastasis came from and guide treatment for an unknown primary.
IHC uses lab antibodies to stain tumor tissue; it does not measure the patient's own antibodies.
Biology & staging
A clinical trial protocol is amended to add a mandatory research biopsy. For participants already enrolled, the research nurse must:
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A new procedure with added risk is significant new information, so the revised consent goes through the IRB and each enrolled participant must agree before the biopsy.
Telling participants informs them but does not obtain their agreement to an added procedure.
A procedure added after enrollment needs the participant's agreement; the protocol change alone gives no consent.
A letter informs without documenting agreement, so the biopsy would still lack consent.
Biology & staging
Which type of thyroid cancer is the most common and usually has an excellent prognosis?
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Follicular carcinoma is also well differentiated with a good outlook, but it is much less common than papillary.
Anaplastic carcinoma is rare and among the most aggressive cancers, with a poor prognosis.
Papillary carcinoma makes up most thyroid cancers and is usually cured with surgery, with radioactive iodine when indicated.
Medullary carcinoma comes from parafollicular cells and accounts for only a small share of cases.
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II.A Scientific basis: carcinogenesis, immunology, clinical trials and research protocols, genomic testing of the tumor (including next-generation sequencing) and genetic testing of the person.
II.B Cancer by site: pathophysiology, biopsy and imaging, the usual sites of spread, staging and histologic grade, and performance status.
II.C Scope and standards: practice evaluation and accreditation, teamwork, culturally congruent care, occupational safety, advocacy and ethics, the nurse's own well-being, and documentation through the nursing process.
How a TNM stage is built
TNM staging in the United States follows the AJCC Cancer Staging Manual, 8th edition (2017), which AJCC now revises site by site as Version 9 protocols. Three letters describe the anatomy:
T is the size or local extent of the primary tumor (Tis for carcinoma in situ, then T1–T4).
N is spread to regional lymph nodes (N0 for none, then N1–N3 by number or location).
M is distant metastasis, either M0 or M1.
Prefixes say when and how the stage was assigned: clinical classification uses exam, imaging and biopsy before treatment, pathologic classification uses the surgical specimen, a y marks staging after neoadjuvant therapy and an r marks a recurrence. The T, N and M categories are then combined into a stage group from 0 to IV. For several sites the group also depends on factors that are not anatomy at all, such as grade, PSA or hormone receptor and HER2 status for breast cancer, which is why two breast tumors of the same size can land in different prognostic stage groups.
Testicular cancer adds a fourth letter: S, for serum tumor markers (AFP, beta-hCG and LDH), measured after orchiectomy.
Grade, performance status and tumor markers
Grade is about the cells, stage is about the spread. A pathologist grades how much the tumor cells differ from normal tissue, from well differentiated (low grade) to poorly differentiated or undifferentiated (high grade); many sites use their own system, such as the Nottingham score for breast cancer or Grade Groups for prostate cancer.
Performance status measures what the patient can do, and it drives eligibility for treatment and trials. The two common scales run in opposite directions: the ECOG (Zubrod) scale goes from 0, fully active, to 5, dead; the Karnofsky scale goes from 100, normal, down to 0 in steps of 10.
Most serum tumor markers are used to follow a known cancer, not to find one.
Marker
Where it is used
CA 15-3, CA 27.29
metastatic breast cancer, alongside imaging, during treatment
CEA
colorectal cancer, after resection and during treatment
From hallmarks to genes: the science under area II
Hanahan and Weinberg’s “The Hallmarks of Cancer” (2000) named six capabilities a cell gains on the way to malignancy: its own growth signals, deafness to signals that stop growth, escape from programmed cell death, unlimited replication, new blood vessel growth, and invasion and metastasis. Their follow-up, Hanahan and Weinberg’s “Hallmarks of Cancer: The Next Generation” (2011), added reprogrammed energy metabolism and escape from immune destruction, plus genome instability and tumor-promoting inflammation as enabling traits; Hanahan’s “Hallmarks of Cancer: New Dimensions” (2022) proposed four more candidates: phenotypic plasticity as a hallmark, nonmutational epigenetic reprogramming and polymorphic microbiomes as enabling characteristics, and senescent cells in the tumor microenvironment.
Two gene families sit at the center of carcinogenesis. Proto-oncogenes such as HER2 (ERBB2) and KRAS drive growth when a gain-of-function change switches them on, and one altered copy can be enough. Tumor suppressor genes such as TP53, RB1 and BRCA1/2 stop growth or repair DNA, and usually both copies have to be lost, the two-hit model from Knudson’s retinoblastoma study (1971).
Genetic and genomic testing answer different questions. Germline (genetic) testing looks at inherited variants present in every cell, such as BRCA1/2 or the Lynch syndrome genes, and its results matter for relatives, who may be offered cascade testing. Tumor (genomic) testing, often by next-generation sequencing of tissue or of circulating tumor DNA in blood, looks for changes acquired by the cancer that point to a targeted drug, such as EGFR or ALK in lung cancer or mismatch repair deficiency. A tumor result can hint at an inherited variant, but only a germline test confirms it.
Trials, ethics and caring for the caregiver
Clinical trial phases follow the drug's path: phase I sets the dose and schedule while watching safety, phase II measures whether a defined cancer responds, phase III pits the newcomer against current standard care, usually by randomization, and phase IV keeps watching once the drug is on the market. The nurse's part includes checking eligibility against the protocol, giving treatment exactly as written and reporting adverse events by CTCAE grade.
For US nurses, professional ethics starts from the ANA Code of Ethics, 2025 edition. Self-care was already in the 2025 outline, with compassion fatigue as its example; the 2026 outline adds burnout and substance use. The three words are not interchangeable:
Compassion fatigue combines burnout with secondary traumatic stress from repeated exposure to patients' suffering; the ProQOL, Professional Quality of Life measure (Stamm) scores both alongside compassion satisfaction.
Restaging a recurrence. The stage assigned at diagnosis stays on the record; a later recurrence is described with it (an r prefix if it is staged again), not by rewriting it.
Reading M1 as stage IV everywhere. That holds for most solid tumors, not all: under AJCC 8th edition, differentiated thyroid cancer in a patient younger than 55 is stage II even with distant metastases.
Using grade and stage as synonyms. A small, localized tumor can be high grade, and a large one low grade.
Reading the ECOG and Karnofsky numbers the same way. A higher ECOG number is worse; a higher Karnofsky number is better.
Taking a tumor sequencing report as a hereditary result. It describes the cancer; inherited risk needs a germline test and genetic counseling.
ONCC does not name an edition in the outline. The AJCC 8th edition, with the site chapters AJCC has since moved to Version 9, is what US cancer programs stage with now, so learn its rules rather than older ones.
What changed in area II on the 2026 outline?
Its weight fell from 17% to 15%. Genomic testing and next-generation sequencing became a line separate from genetic testing, performance status was added, and the standards list was shortened, with leadership and research no longer listed on their own.
Is the ECOG scale the same as the Zubrod scale?
Yes. The ECOG performance status, also called the WHO or Zubrod scale, runs from 0 to 5.
Domain IV · Symptom Management and Supportive Care25%
06Neutropenia and myelosuppressionAbsolute neutrophil count, neutropenic precautions, febrile neutropenia and the first hour of sepsis, growth factors, bleeding precautions, anemia and transfusion.
07Symptom management and supportive careNausea and vomiting, bowel changes, mucositis, neuropathy, fatigue, skin and hair changes, lymphedema and ostomies, nutrition and weight loss, pain, and complementary therapies.
Domain III · Treatment Modalities20%
03Chemotherapy, targeted therapy and immunotherapyDrug classes and how they work, checkpoint inhibitors, CAR T cells and bispecific antibodies, hormonal agents, oral therapy and adherence teaching, intrathecal and intravesical therapy, and recognizing immune-related toxicity.
04Safe chemotherapy administration and handlingOrder checks and independent double checks, dose and body surface area, hazardous drug handling and spills, protective equipment, infusion reactions, and first steps when a vesicant leaks.
05Radiation, surgery and transplantSurgical and procedural care, radiation principles and safety (time, distance, shielding; sealed and unsealed sources), common site effects, and an overview of autologous and allogeneic transplant.
Domain V · Oncologic Emergencies16%
08Oncologic emergencies: structural and treatment-relatedSuperior vena cava syndrome, spinal cord compression, cardiac tamponade, raised intracranial pressure, obstructions and pneumonitis, with a map of all sixteen Domain V emergencies.
09Tumor lysis syndrome and metabolic emergenciesTumor lysis syndrome, SIADH, hypercalcemia of malignancy, DIC and venous thromboembolism: who is at risk, the labs, and what the nurse does first.
01Care continuum: prevention, screening and survivorshipRisk factors, screening and prevention, navigation, survivorship care plans and late effects, advance care planning, and end-of-life and hospice care at the level the OCN exam tests.
Domain VI · Psychosocial Dimensions of Care10%
10Psychosocial care in oncologyDistress screening, coping, body image, sexuality and fertility, learning needs, cultural and spiritual care, caregiver strain, crises, and the cost of cancer care.