Clinical approaches to a cancer patient Flashcards
Cancer is a term for diseases in which abnormal cells divide without control, characterized by local tissue invasion and distant metastases
Cancer is a term for diseases in which abnormal cells divide without control, characterized by local tissue invasion and distant metastases
Oncology is the medical subspecialty dealing with the study and treatment of cancer
Oncology is the medical subspecialty dealing with the study and treatment of cancer
1 in ____ sg dies of cancer
1 in 4 sg dies of cancer
________ppl dies from cancer everyday
14 ppl dies from cancer everyday
_____ ppl diagnosed w cancer everyday
28 ppl diagnosed w cancer everyday
top 3 men cancer incident
- Colorectal Cancer (17.1%)
- Lung Cancer (15.1%)
- Prostate Cancer (12.4%)
men Colorectal Cancer rank and %
incident
- Colorectal Cancer (17.1%)
men Lung Cancer rank and %
incident
- Lung Cancer (15.1%)
men Prostate Cancer and %
incident
- Prostate Cancer (12.4%)
men top 3 cancer death
- Lung Cancer (27.1%)
- Colorectal Cancer (13.8%)
- Liver Cancer (12.6%)
men Lung Cancer rank and %
death
- Lung Cancer (27.1%)
men Colorectal Cancer rank and %
death
- Colorectal Cancer (13.8%)
men liver Cancer rank and %
death
- Liver Cancer (12.6%)
women cancer incident
- Breast Cancer (29.2%)
- Colorectal Cancer (13.3%)
- Lung Cancer (7.6%)
women Breast Cancer rank and %
incident
- Breast Cancer (29.2%)
women colorectal Cancer rank and %
incident
- Colorectal Cancer (13.3%)
women lung Cancer rank and %
incident
- Lung Cancer (7.6%)
women cancer death
- Breast Cancer (17.6%)
- Lung Cancer (16.5%)
- Colorectal Cancer (15.2%)
women death breast cancer rank and %
- Breast Cancer (17.6%)
women death lung cancer rank and %
- Lung Cancer (16.5%)
women death colorectal cancer rank and %
- Colorectal Cancer (15.2%)
treatment goals
- To cure
- To prolong life
- To palliate
- To experiment
- To Cure
Overall 70% of germ cell tumors can be cured with chemotherapy alone
Overall 50% of lymphomas can be cured with chemotherapy alone
More than 90% of standard risk testicular cancers are curable
2. To Prolong life The traditionally highly treatable cancers are usually the “hormonal” types § Breast § Ovarian § Thyroid § Prostate
§ With the advent of molecular therapies and immunotherapies, traditionally treatment-resistant cancers are becoming highly amenable to treatment
Cure and prolong –> fine line grey area. coz tx is v good.
- To Palliate (due to recur/resistance)
“ Living well may not add years to your life, but it will add meaning to your years
§ Treat when not treating leads to lower quality of life
§ Illness-related concerns
- Symptom distress
§ Social-related concerns
- Maintaining normalcy
- to give comfort
- low dose chemo/radio to increase QOL and ddecrease symptoms / stress
To Experiment
§ Reasonable option to offer a patient with relapsed or refractory disease
§ Not an option if gold standard therapies are still available…or rather, is it ethical to offer experimental treatment over gold standard treatment?
§ Phase I studies (no guarantee cure)
must have exhausted all standarised tx and gold std
BAD prognosis (in survival rate)
<80-90% 5 year survival rate = bad prognosis
Tolerance of side effects in tx goal
Cure = high
Extend life = moderate
Pallitive = low
Experimental = expected
special concerns for Cure goal
Delayed and late side effect
- eg leukaemia cure rate of 80% –> cardiomyopathy –> die from Heart failure in 30-40yo.
special concerns for extend life goal
value of added time
pt live longer okay?
special concerns for pallitive goal
symptoms control
special concerns for experimental goal
finding correct dose
Challenges in patient selection and management
Cure goal
Avoid treating those who are already cured
Challenges in patient selection and management
extend life goal
Treat when added time outweighs side effects
Challenges in patient selection and management
palliative goal
Treat when not treating leads to lower quality of life
Challenges in patient selection and management
experiment goal
respond ethically to patient’s perception of intent
Factors to consider in determining treatment goals
§ Type of cancer and extent of involvement § Treatment goals § Age § Performance status § Concomitant diseases § Social and economic factors § Patient’s and/or family member’s wishes § and many more..
ECOG and KARNOFSKY
performance status scales ECOG 0-5 0 = normal activity 1 = symptoms but ambulatory both outpatient
2 = <50% in bed
3 =>50% in bed
4= 100% in bed
5 = death
KARNOFSKY
- 100% normal
70-100 = outpatient
0 = dead
cellular kinetics
10^12 = 1 kg = Severe metastatic disease, death
10^11 = 100 gm = Advanced metastases
10^10 = 10 gm = Regional spread of cancer
10^9 = 1 gm = Clinically detectable disease (symptoms)
10^8 = 100 mg= Subclinical disease 10^4 = 1 mg = Subclinical disease
10^3 = 1 mcg = Carcinoma in situ 10^0 = 1 ng = Neoplastic Transformation
slow growing vs rapid growing cancer tx
Chemo / cytotoxic only for rapid growing cancer.
eg of slow growing cancer
prostate and kidney cancer
____ log kill, ___ log regrowth
3 log kill, 1 log regrowth
chemotherapy concepts
target = below 10^9 and continue till 0 cells
interval for chemotherpy = 3 weeks
so as to allow body to recover.
chemo can kill bonemarrow cells, therefore WBC etc drops.
recovery phase allow cancer cells to regrowth and also allow WBC to increase in number
shorten interval for chemotherapy by giving WBV growth factor. interval shorten to 2 months.
thus less time for cancer to growth but increase toxicity
Different Modalities of cancer treatment
- Surgery
- Radiation
- Hematopoietic Stem Cell Transplant
- Hormonal Therapy
- Targeted Therapies
- Immunotherapy
- Chemotherapy
Surgical oncology
Surgical oncology (solid tumor; normally combi) § The most ancient mode of treatment for cancer; It was the only treatment that could cure cancer prior to the advent of chemotherapy and radiotherapy
Multiple roles § Preventive (prophylactic) surgery § Diagnostic and staging surgery § Debulking surgery § Palliative surgery
Radiation Therapy (XRT)
Destruction of cancer cells by ionizing radiation; treats localized disease
§ Rarely used by itself with curative intent; parts of multi-modality treatment approach
Many techniques available
§ Internal Interstitial Radiation (Brachytherapy) § External Beam Radiation therapy
Complications of XRT
Radiation Therapy (XRT)
Acute: Interruption of rapidly dividing tissues; patients can become fatigue, develop skin reactions, nausea, vomiting, diarrhea, dysphagia, mucositis, xerostomia, myelosuppression
Chronic: Pulmonary fibrosis, tissue edema, may induce secondary malignancies
XRT is mutageneic, carcinogenic and teratogenic
stem Cell Transplantation
Stem Cell Transplantation
§ Administration of higher than usual myelosuppressive chemotherapy and/or radiation therapy to treat a malignancy or to replace a diseased bone marrow
Types of Transplants: § Allogeneic (other ppl) § Autologous (own stem cell) § Syngeneic § Cord Blood Transplant
Hormonal Agents
Hormonal Agents
§ aka Hormonal Antagonists
§ Manipulation of the endocrine therapy through exogenous administration of specific hormones as number of cancers are driven by the hormones
§ Castration of hormones can be performed by pharmacological or surgical means
- stop production of certain hormones
OR - hormones will not bind to receptors and stimulate growth
targeted therapies
§ Molecularly targeted therapy is a type of medication that blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth
Two main categories
§ Monoclonal antibodies
§ Tyrosine kinase inhibitors
Immunotherapy
Immunotherapy
§ Using the immune system to detect and destroy cancer
Some examples include:
§ Immune system modulators
- Interleukins and interferons
§ Monoclonal antibodies (targeted)
§ Immune Checkpoint Modulators
§ Cancer Treatment vaccines
§ Immune Cell Therapies
chemotherapy
- Chemotherapy
§ Induction —- 1st tx that bring pt to remission (10^9)
§ Consolidation — more chemo to maintain remission
§ Maintenance – v. low dose chemo to maintain remission/cure —- after finishing consolidation tx
(haematological cancer)
§ Adjuvant — tx given after surgery to maintain remission
§ Neoadjuvant – chemo given before surgery to shrink tumor down before cutting it—- after that can start adjuvant
Goals of combination therapy
increased efficacy
balance between activity and safety (compatible side effect)
activity = different mechanism of action and resistance
only give drug that has response rate of >=30%
response rate = tumor size reduction
Body surface area formula
Sq rt [ ( Height(cm) X weight (Kg) ) / 3600 ]
Dose rounding is recommended not to exceed _________
Dose rounding is recommended not to exceed 5-10%
Tumor factors that affect cell kill
Heterogeneity: Tumor cells are generally unstable and tend to form different cell clones (mutation –> various response –> resistant)
§ Site —> BBB, Bone hard to penetrate
§ Size - the larger the tumor:
- The greater the heterogeneity
- The poorer vascularization
- The smaller the growth fraction (Gompertzian Growth)
- Drug resistance – many mechanisms
Administration Sites of Chemotherapy
Systemic Administration
§ Intravenous
§ Intramuscular
§ Subcutaneous
Local/regional administration § Intraperitoneal § Intrathecal and intraventricular § Intravesical § Intra-arterial (Hepatic Arterial and regional limb perfusion )
Pros and Cons of systemic therapy
Pros
§ Treat micrometastasis (clinically undetectable tumor) § Prevents systemic recurrence
§ Effective for treatment of widespread tumor sites
Cons
§ Increases toxicity to a wide range of tissues and organ systems throughout the body
§ ↑ risk of life-threatening toxicity
§ ↑ risk of systemic symptoms
Pros and Cons of Regional therapy
PROS § Provide high dose to specific site § Low risk of systemic toxicities § Low rates of systemic symptoms § May allow treatment in patient unable to tolerate systemic system
CONS § Do not treat micrometastasis § ↑ risk of systemic failure § Tumors needs to be localized § Technically difficult? § May require drugs with specific characteristics that allow for regional administration
Evaluate of treatment response
“How do I know whether my treatment is going well or not?”
§ Responses – Complete Response, Partial Response, Stable Disease
§ Survival – Overall Survival, Progression Free Survival
§ Tumor markers – e.g. CA-125, CEA
§ Quality of life
Complications of systemic anticancer therapies
Diarrhea
Renal failure
cystitis local reaction alopecia myalgia pulmonary fibrosis sterility
neuropathy
myelosuppression
phlebitis
cardiotoxicity
mucositis
Vomiting / nausea
cognitive impairment
grading chemotherpay toxicities (dehydration)
1: dry mucous membranes and/or diminished skin turgor
2: requiring IV fluid replacement (brief)
3) requiring IV replacement (sustained)
4) physiologic consequences requiring intensive care, hemodynamic collapse.
3/4 = can cause death need interrupt tx and give supportive tx.
adverse events
§ Dose limiting toxicity – can limit the amount of drug exposure to a patient
§ Hematological toxicities
- Objective toxicities e.g. neutropenia
- Clear guidelines to withhold or delay
§Non-hematological toxicities
- Often subjective toxicities e.g. fatigue
- Individual threshold varies
§ Economics of managing AE-related admissions
- Direct Medical Costs = SGD$ 4747
- Length of stay ~ 6.1 days
Cancer Supportive Care Defined
Supportive care is a discipline within oncology which is devoted to the ____________ associated with cancer and anticancer treatment, with an ultimate aim to alleviate cancer patients’ symptoms and complications. This includes the management of _____________ and side effects that patients experience across the __________
Supportive care is a discipline within oncology which is devoted to the
prevention and treatment of toxicities
associated with cancer and anticancer treatment, with an ultimate aim to alleviate cancer patients’ symptoms and complications. This includes the management of
physical and psychological symptoms
and side effects that patients experience across the
continuum of the cancer.
