Cancer Diagnosis and Staging

Question 1

Why is the right diagnosis key?

Answer 1

To provide the right treatment

Question 2

In terms of clinical diagnosis of cancers, are GPs generalists or specialists?

Answer 2

Specialists

Question 3

What does cancer staging guide?

Answer 3

Therapy

Question 4

What is a cancer diagnosis?

Answer 4

Identification of the disease process, i.e. is it cancer? What type is it?
Can be broad or specific
Identification of predictive and prognostic biomarkers

Question 5

What percentage of malignancies diagnosed in primary care for patients aged 70 or over are treated as emergency admissions?

Answer 5

31%

Question 6

What would a primary care clinician look at for a diagnosis?

Answer 6

Symptoms
Patient history: history of complaint, history of illnesses, risk factors in lifestyle
Examination - 'signs'
Blood tests
Simple imaging, e.g. CXR

Question 7

What happens after a patient is diagnosed with cancer in primary care?

Answer 7

They are referred to a hospital specialist

Question 8

What would a hospital specialist look at for a diagnosis?

Answer 8

Retake history, examination and blood tests
Imaging, e.g. X-ray, CT, ultrasound, PET scan
Formulation of differential diagnosis

Question 9

Give an example of a differential diagnosis for a patient presenting with weight loss, haemoptysis, and lung mass

Answer 9

Infective, e.g. pneumonia, TB
Autoimmune, e.g. vasculitis
Tumour, benign or malignant

Question 10

What would be the next steps after a patient has been referred and assessed by a hospital specialist?

Answer 10

Tissue diagnosis

Question 11

What happens during tissue diagnosis?

Answer 11

Definitive answer is reached
Biopsy
Cytology, of FNA, body fluids, e.g. pleural effusion

Question 12

What are the three types of biopsy?

Answer 12

Minimally invasive, e.g. fibreoptic bronchoscopy

Invasive, e.g. CT-guided needle biopsy OR open surgery/VATS/frozen section

Question 13

What happens during a frozen section biopsy?

Answer 13

Immediate tissue diagnosis
Useful during surgery
Fresh tissue is frozen, unfixed, stained and examined in minutes
Result is telephoned to surgery

Question 14

Diagnosis can be prognostic, true or false?

Answer 14

True

Question 15

Diagnosis can be predictive, true or false?

Answer 15

True

Question 16

How might tissue diagnosis change in the future?

Answer 16

Molecular tests/biomarkers will become increasingly important: currently direct therapy and have a growing diagnostic role
Role of H&E staining is diminishing
May be some alternatives to tissue biopsy, e.g. liquid biopsy

Question 17

What are the technical challenges of a liquid biopsy?

Answer 17

Isolation of material
DNA sequencing apporach
Interpretation of data
No ‘dictionary’

Question 18

What is the main controvery surround liquid biopsies?

Answer 18

Is imaging and blood tests as good as a tissue biopsy?

Question 19

What is a liquid biopsy?

Answer 19

Tumour DNA can be detectable in the bloodstream from circulating tumour cells and cell-free DNA
Specific mutations are detectable

Question 20

What is an accurate diagnosis essential for?

Answer 20

Prognosis and therapy

Question 21

What is the hierarchy of cancer investigations?

Answer 21

GP, radiologist, physician, surgeon, pathologist

Question 22

Diagnostic tests are no longer improving, true or false?

Answer 22

False, they are improving

Question 23

Molecular tests are becoming ubiquitous, true or false?

Answer 23

True

Question 24

What do more treatments and more effective treatments mean about testing?

Answer 24

More complexity of testing

Question 25

What is the current cancer staging model?

Answer 25

TNM

Question 26

In cancer staging, what is T in the TNM model?

Answer 26

‘Tumour’

Size and which tissues are involved

Question 27

In cancer staging, what is N in the TNM model?

Answer 27

‘Nodes’

Is there regional nodal metastasis? Which groups of nodes are involved?

Question 28

In cancer staging, what is M in the TNM model?

Answer 28

‘Metastasis’

Distant site involvement

Question 29

Does cancer stage indicate prognosis?

Answer 29

Yes

Question 30

Fundamentally, what does staging determine?

Answer 30

Whether a treatment is curative in intent (surgical or medical therapy needed)

Question 31

What is correct cancer staging essential for?

Answer 31

Giving the best treatment as both over and under treating is bad for the patient

Question 32

The staging criteria are set in stone, true or false?

Answer 32

False, they are always under review as ‘curability’ varies over time

Question 33

Describe ‘personalised’ biological therapies

Answer 33

Small molecules/antibodies that target sensitive subgroups of tumours
Treatment must be matched to case using biomarkers and sequencing/FISH/IHC on tumour material

Question 34

Give examples of some ‘personalised’ biological therapies

Answer 34

Tamoxifen, herceptin, tyrosine kinase inhibitors

Question 35

What is cancer staging?

Answer 35

It describes how far the disease has progressed using tumour size and its spread within the body
Prognostic and guides therapy

Question 36

How is clinical staging formulated?

Answer 36

From examination and imaging

Question 37

How is pathological staging different from clinical staging?

Answer 37

Pathological staging is more precise and depends upon prior surgery

Question 38

Describe the cancer staging criteria

Answer 38

Number system vs. TNM system
Highly detailed, organ-specific
Regularly updated

Question 39

What is the purpose of the multidisciplinary team meetings (MDT)?

Answer 39

To discuss new diagnoses of malignancy and post-surgery management
One per speciality

Question 40

Who is involved in the MDT meetings?

Answer 40

The whole clinical team…
Physicians, surgeons, radiologist, pathologist, oncologist, specialist nurses, radiotherapist, MDT coordinator, palliative care specialist etc.

Question 41

What happens at an MDT meeting?

Answer 41

Each case is presented, correlated with imaging, pathology, nursing needs
Clinical plan is formulated