Cancer Flashcards
What is oncology?
a branch of medicine that deals with the prevention, diagnosis, and treatment of cancer
How does cancer develop?
as cells become abnormal, old or damaged cells survive when they should die and new cells form when they are not needed
these extra cells can divide without stopping and may form growths called tumours
many cancers form solid tumours (masses of tissue)
blood cancers do not generally form solid tumours
What is a malignant tumour?
a tumour that can spread into, or invade, nearby tissues
as these tumours grow, some cancer cells can break off and travel to distant parts of the body through the blood or lymphatic system and form new tumours far from the original tumour
What is a benign tumour?
a tumour that does not spread into, or invade, nearby tissues
can sometimes be quite large
when removed, does not usually grow back (malignant tumours sometimes do)
benign brain tumours can be life-threatening
Why is cancer a genetic disease?
it is caused by changes to genes that control the way our cells function, especially how they grow and divide
What causes genetic changes?
hereditary UV radiation chemicals viruses smoking cells dividing
What are somatic genetic changes?
alterations to DNA after birth
not hereditary
related to external factors
What are familial cancers?
can be hereditary and passed down in DNA
classed as germline mutations
The genetic changes that contribute to cancer tend to affect which three main types of genes?
proto-oncogenes
tumour suppressor genes
DNA repair genes
What are proto-oncogenes?
involved in normal cell growth and division
when these genes are altered in certain ways or become more active than normal, they may become cancer-causing genes (oncogenes), allowing cells to grow and survive when they should not
What are tumour suppressor genes?
involved in normal cell growth and division
cells with certain alterations in tumour suppressor genes may divide in an uncontrolled manner
What are DNA repair genes?
involved in repairing damaged DNA
cells with mutations in these genes tend to develop additional mutations in other genes
together, these mutations may cause the cells to become cancerous
How many new cancer cases were recorded worldwide in 2018?
17 million
How many new cancer cases are recorded in the UK each year?
363,000
How many new cancer cases were recorded in females in the UK in 2016?
178,000
How many new cancer cases were recorded in males in the UK in 2016?
185,000
Breast, prostate, lung, and bowel cancers together accounted for what percentage of new cancer cases recorded in the UK in 2016?
53%
What age group in the UK has seen the greatest increase in new cancer cases since the 1990s?
0-24 years
What age group in the UK had the highest incidence rates for all cancers combined between 2014 and 2016?
85-89 years
What age group has the highest recorded number of cancer cases in the UK?
58-89 years
What percentage of all cancer cases occur in 0-24-year-olds?
1%
What percentage of all cancer cases occur in 25-49-year-olds?
10%
What percentage of all cancer cases occur in 50-74-year-olds?
53%
What percentage of all cancer cases occur in 75+-year-olds?
36%
What are the two most common types of cancer in females aged 25-49 years?
breast cancer 44%
melanoma 9%
What are the two most common types of cancer in females aged 50-74 years?
breast cancer 34%
lung cancer 13%
What are the two most common types of cancer in females aged 75+ years?
breast cancer 22%
lung cancer 16%
What are the two most common types of cancer in males aged 25-49 years?
testicular cancer 14%
melanoma 11%
What are the two most common types of cancer in males aged 50-74 years?
prostate cancer 30%
lung cancer 13%
What are the two most common types of cancer in males aged 75+ years?
prostate cancer 24%
lung cancer 16%
What cancer screening tests are available in the UK?
breast screening
cervical screening
bowel screening
What patient population is offered breast screening?
women aged 50-70 years
a trial is being undertaken to establish the suitability of screening between 47-73 years
What patient population is offered cervical screening?
women aged 25-49 years every three years
women aged 50-64 years every five years
What patient population is offered bowel screening?
men and women aged 60-74 years
offered to men aged 50-74 years in Scotland
bowel scoping offered to those aged 55 years in England
What are the two main systems of cancer staging?
TNM (tumour, node, metastasis) number staging (1-4)
What is the TNM (tumour, node, metastasis) system?
describes the size of the initial cancer (primary tumour), whether the cancer has spread to the lymph nodes, and whether it has spread to a different part of the body (metastasised)
the system uses letters and numbers to describe the cancer
What does T refer to in the TNM system?
the size of the cancer and how far it has spread into nearby tissue
numbered 1, 2, 3 or 4 (1 is small and 4 is large)
What does N refer to in the TNM system?
whether the cancer has spread to the lymph nodes
numbered from 0 (no lymph nodes containing cancer cells) to 3 (many lymph nodes containing cancer cells)
What does M refer to in the TNM system?
whether the cancer has spread to another part of the body numbered 0 (not spread) or 1 (spread)
What is the number staging system?
TNM system can be used alongside this approach
What does stage 1 refer to in the number staging system?
usually means that a cancer is relatively small and contained within the primary organ
What does stage 2 refer to in the number staging system?
usually means that the tumour is larger than in stage 1, but the cancer has not started to spread into the surrounding tissues
sometimes means that cancer cells have spread to lymph nodes near the tumour
this depends on the particular type of cancer
What does stage 3 refer to in the number staging system?
usually means the cancer is larger
may have started to spread into surrounding tissues
cancer cells present in the lymph nodes in the area
What does stage 4 refer to in the number staging system?
the cancer has spread to another organ (secondary/metastatic cancer)
How is surgery used in oncology?
to diagnose cancer
to cure cancer
to prevent or reduce cancer
palliative to extend life/quality
What factors determine whether surgery is used in oncology?
type of cancer location of tumour size of tumour metastasis the general health of the person
How is chemotherapy used in oncology?
given pre-surgery (neoadjuvant) or post-surgery (adjuvant) to prevent cell division of the mutated cell
medication can be combined to treat areas:
MIC is M = mitomycin (late G1 and S), I = ifosfamide (non-specific cell but alkylating agent), C = cisplatin (G2 and M)
List the three routes through which chemotherapy can be delivered.
oral
central line
peripheral inserted central catheter (PICC)
What is meant by a ‘cycle’ of chemotherapy?
refers to the length of time chemotherapy is taken
one cycle refers to one period of the whole cycle in certain cases (e.g. 4-8 cycles that last 3-6 months)
What is a ‘regime’ of chemotherapy?
agreed based on cancer and patient outcomes
a patient may receive chemotherapy on days 1, 2 and 3 in 4 weeks, but will receive none from the 4th-28th in that month
a new cycle begins when the person starts to take the medication again
How is radiotherapy used in oncology?
works by aiming a high dose of radiation towards a person’s tumour which damages cell DNA
How does radiotherapy damage cell DNA?
radiation can directly damage DNA by causing breaks along the strands of genetic material
radiation can trigger the formation of very reactive molecules that can themselves be damaging (e.g. free radicals)
List the two routes through which radiotherapy can be delivered.
internally (radioactive iodine - thyroid cancer)
externally (breast cancer)
List the five cancer sites with the highest 1-year survival in men (ONS, 2019).
- melanoma
- prostate
- testis
- Hodgkin lymphoma
- thyroid
List the five cancer sites with the highest 1-year survival in women (ONS, 2019).
- melanoma
- breast
- thyroid
- Hodgkin lymphoma
- uterus
List the five cancer sites with the lowest 1-year survival in men (ONS, 2019).
- mesothelioma
- brain
- liver
- lung
- pancreas
Name the cancer sites with the highest 5-year net survival in men and women (ONS, 2019).
- oesophagus
- lung
- brain
- liver
- pancreas
Name the cancer site with the highest 5-year net survival in men and women (ONS, 2019).
men - testis (95.3%)
women - melanoma (93.4%
Name the cancer site with the lowest 5-year net survival in men and women (ONS, 2019).
men - pancreatic (6.5%)
women - pancreatic (8.1%)
What was the incidence of breast cancer in the UK in 2016?
54,500
What was the incidence of male breast cancer in the UK in 2016?
360
What proportion of people in the UK will develop breast cancer at some stage in their life?
1 in 7
What proportion of people over the age of 50 will develop breast cancer in the UK?
8 in 10
What was the incidence of breast cancer in people under the age of 50 in the UK in 2016?
10,000
What was the incidence of breast cancer in people under the age of 39 in the UK in 2016?
2,200
On average, how many cases of breast cancer occur in the UK each year?
46,000
What are the two main breast cancer sites?
invasive ductal breast cancer (80%)
invasive lobular breast cancer (10%)
What causes the remaining 10% of breast cancer cases?
inflammatory breast cancer (1-5%)
Paget’s disease (1-4%)
ductal carcinoma in situ (6,700 cases)
lobular carcinoma in situ (710 cases)
What does in situ ductal/lobular carcinoma refer to?
the containment of the abnormal cells within an area (at risk of invasive development)
What does invasive ductal carcinoma refer to?
70%
most invasive have no special features or type
presence can indicate rarer cancers
What does invasive lobular carcinoma refer to?
12.2%
can develop at any age
most common in people aged 45-55 years
What happens in inflammatory breast cancer?
cancer cells block the smallest lymph ducts in the breast
this leads to fluid accumulation and inflammatory mediators due to cancer
What is Paget’s disease?
develops in the nipple or areola
causes redness, scaling and flaking of the nipple
a sign of potential breast cancer in the tissue behind the nipple
List some of the signs and symptoms of in situ ductal carcinoma.
lump in breast
discharge from the nipple
consider general BCA symptoms
List some of the signs and symptoms of in situ lobular carcinoma.
does not usually cause any signs or symptoms
may be seen on a mammogram
List some of the signs and symptoms of invasive ductal carcinoma.
lump/thickening breast
size/shape/feel breast
look - rash on the nipple or around the area
lump - armpit
List some of the signs and symptoms of invasive lobular carcinoma.
thickening or oedema
look - nipple inverted/dimpling
feel - thickened
consider general BCA symptoms
List some of the signs and symptoms of inflammatory breast cancer.
oedema/lump
look - erythema/possible inverted nipple
feel - firm and hot
discharge from the nipple
List some of the signs and symptoms of Paget’s disease.
erythema, scaling/rash on nipple/areola
look - discharge from the nipple and possible inversion
feel - itchy, painful and burning sensation
consider general BCA symptoms
What tests may be used to diagnose breast cancer?
mammogram
ultrasound (more likely for people under 35 years)
MRI (breast)
biopsy - needle aspiration
Name the three types of breast biopsies.
fine needle aspiration
core needle biopsy
open (surgical) biopsy
What is a fine needle aspiration?
collects samples of cells
What is a core needle biopsy?
collects core of tissue
ultrasound or MRI guides process
What is an open (surgical) biopsy?
removes all or part of the abnormality
How is breast cancer identified on a mammogram?
the cancerous mass may appear as a bright and irregular image with spiky or fuzzy edges
How is breast cancer identified in an ultrasound?
the cancerous mass appears darker, indicating it is solid
it may have spiky or irregular edges
How is breast cancer identified on MRI?
contrast agent causes the cancerous mass (or outside of mass) to brighten, then fade
irregular or spiky borders are common
How is breast cancer identified in a biopsy?
under a microscope, cancer cells may:
appear clustered
have irregular, large, or additional nuclei
invade blood or lymphatic vessels
How is breast cancer staged?
TMN number stages 1-4 grading (microscope) low grade - 1 (slow growing) intermediate grade - 2 high grade - 3 (faster growing)
What does ER refer to in a tumour biopsy?
oestrogen positive/negative
What does PR refer to in a tumour biopsy?
progesterone positive/negative
What does HER2 refer to in a tumour biopsy?
Herceptin positive/negative
What is meant by the term ‘early breast cancer’?
cancer has not spread beyond the breast or lymph nodes in the armpit on the same side of the body
What is meant by the term ‘local recurrence’?
cancer has returned in the same area of the breast after treatment
What is meant by the term ‘locally advanced breast cancer’?
cancer has not spread to another part of the body, but might be:
bigger than 5cm in diameter
growing into the skin or muscle of the chest
present in the lymph nodes in the armpit, and the nodes are stuck to each other or to other structures
What is the treatment for invasive breast cancer?
surgery (mastectomy/lumpectomy)
radiotherapy
chemotherapy
hormonal
What is the treatment for in situ breast cancer?
surgery (mastectomy/lumpectomy)
possible radiotherapy
hormonal
What is the treatment for inflammatory breast cancer?
chemotherapy (neoadjuvant)
surgery (mastectomy/lumpectomy)
radiotherapy
hormonal
What is the treatment for Paget’s disease?
sentinel biopsy
possible surgery, radiotherapy or chemotherapy (variable)
What is the hormonal treatment for breast cancer?
ER + oestrogen receptor blocker + tamoxifen
ER + aromatase inhibitors (AIs) convert lipids into oestrogen:
anastrozole (Arimidex)
letrozole (Femara)
exemestane (Aromasin)
HER2 + Herceptin blocker = trastuzumab
What is the hormonal treatment for breast cancer pre-menopause?
tamoxifen for 5 years with a potential for this to continue for another 5 years
AI given if tamoxifen not tolerated
What is the hormonal treatment for breast cancer post-menopause?
anastrozole or letrozole for 5 years, OR
one of these drugs for 2 years followed by tamoxifen for 3 years
tamoxifen given for 5 years if AI not tolerated
other options:
tamoxifen for 2-3 years and then AI to total of 5 years
tamoxifen for 5 years and then letrozole for another 5 years
How long do follow-ups usually last for breast cancer?
5 years
What do follow-ups involve?
outpatient appointment with CNS or member of the medical team
mammogram/biopsy if needed
What is the survival rate for patients with stage 1 breast cancer?
around 98% for 5+ years after diagnosis
What is the survival rate for patients with stage 2 breast cancer?
around 90% for 5+ years after diagnosis
What is the survival rate for patients with stage 3 breast cancer?
around 70% for 5+ years after diagnosis
What is the survival rate for patients with stage 4 breast cancer?
around 25% for 5+ years after diagnosis
the cancer is not curable at this stage, but may be controlled with treatment for several years
What is chronic oedema/lymphoedema (The National Lymphoedema Partnership, 2014)?
a term used to describe a group of conditions characterised by the presence of swelling within body tissues, caused by the accumulation of excess fluid within the interstitial space of the affected area
What causes oedema?
an imbalance between capillary filtration into and lymphatic drainage from the interstitial space
damage to lymph nodes/vessels
What is the normal duration of chronic oedema?
over 3 months
in other situations, diagnosis/treatment may occur during the first 3 months of symptoms
What are the functions of the lymphatic system?
fluid balance - to gather plasma and its constituents (protein, water, hormones, bacteria, enzymes, fats, waste products)
to act as a defence mechanism against bacteria and mutant cells
What are the different types of lymphoedema?
primary secondary trauma parasitic cancer vascular infection/inflammation obstruction/sedentary
What is primary lymphoedema?
relates to disturbances in the development of the lymphatic system which may or may not be genetic
over 24 different types of primary lymphedema with at least 9 causal mutations known for inherited human lymphedema
may present at birth or later in life
What is secondary lymphoedema?
damage to the lymphatic system due to extrinsic factors
more common than primary lymphoedema
List some examples of extrinsic factors that may cause secondary lymphoedema.
parasitic infection
obstruction/destruction of vessels (tumour, surgery, excision, radiotherapy)
scarring, trauma, inflammation, infection
venous disease - lymphovenous oedema
immobility/obesity
Name two types of trauma that can cause lymphoedema.
burns
necrotising fasciitis
Name one parasitic infection that can cause lymphoedema.
filariasis - an infectious tropical disease caused by any one of several thread-like parasitic roundworms
Name two types of cancer that can cause lymphoedema.
breast
head and neck
Name two types of vascular disease that can cause lymphoedema.
venous disease
DVT
Name one type of infection that can cause lymphoedema.
cellulitis
What is the average caseload of patients who access lymphoedema services (Cooper and Bagnall, 2016)?
78% female 20% male 2% children 60% non-cancer - venous/obesity 40% cancer - breast
What is lipoedema?
females only - 1 in 72,000
genetic involvement suspected
bilateral - symmetrical swelling from the iliac crest to ankles
dorsum of feet never involved
Stemmer’s sign negative
little or no pitting -soft tissue texture
painful to palpate - bruise easily
What are the characteristics of stage 1 lipoedema?
skin appears smooth
on palpation, the thickened subcutaneous tissue contains small nodules
What are the characteristics of stage 2 lipoedema?
skin has an irregular texture that resembles the skin of an orange
subcutaneous nodules occur that vary from the size of a walnut to an apple
What are the characteristics of stage 3 lipoedema?
the indurations are larger and more prominent than in stage 2
deformed lobular fat deposits form, especially around the thighs and knees, and may cause considerable distortion of the limb profile
What are the characteristics of stage 4 lipoedema?
lipoedema with lymphoedema (lipolymphoedema)
List some of the physical signs of lymphoedema.
distortion hyperkeratosis erythema positive Stemmer sign papillomatosis distortion
List some of the physical symptoms of lymphoedema.
heaviness
aching
feels like bruising
hinders mobility
What factors do clinicians take into account in the assessment and diagnosis of lymphoedema?
past medical history lymphoedema history medication pain/discomfort functional assessment impact on quality of life physical examination
What tools can clinicians use when physically examining patients with lymphoedema?
tape measure
bioelectrical impedance analysis (BIA) - estimates cellular fluid volume
moisture meter - converts fluid volume into a percentage
What is the link between an acute inflammatory episode/cellulitis and lymphoedema?
cellulitis can be a cause or a complication of lymphoedema
lymphoedema increases the risk of cellulitis by 72 times
cellulitis is also linked to hospital admissions and can lead to sepsis and death
Clinicians may perform an arterial assessment to rule out which disease?
peripheral arterial disease (PAD)
What is phase 1 of decongestive lymphatic treatment (DLT)?
intensive treatment to improve the severity of the condition and to educate the patient
What is phase 2 of decongestive lymphatic treatment (DLT)?
aim is for the patient to be able to complete self-management of their condition
What skin care products can be prescribed for patients with lymphoedema?
bath additives
emollients
steroid creams
List some types of exercise that can be beneficial for patients with lymphoedema.
dragon boat racing yoga resistance (weights) swimming gentle
What is manual/simple lymphatic drainage (MLD/SLD)?
the use of hand pressure in a particular sequence to facilitate the movement of fluid out of the limb
by moving fluid it reduces the risk of cellulitis and thickening of the tissues
assists in the breakdown of the tissues
relieves discomfort
List some types of compression therapy used to manage lymphoedema.
bandages
hosiery
wrap-based systems
overnight garments
Compression therapy is based on which law?
law of Laplace
What does the law of Laplace state?
the tension within the wall of a sphere filled to a particular pressure depends on the thickness of the sphere
this means that even at constant pressure, the tension within a filled sphere can be decreased simply by increasing the thickness of the sphere’s wall
List some other treatments for lymphoedema.
oscillation negative pressure inflating boots kinesiology tape low-level light
What surgery can be used to treat lymphoedema?
lymph node transplants
lymphatic venous anastomosis
