Introduction to the Diagnosis and Treatment of Cancer

Question 1

When are adult cancers normally diagnosed?

Answer 1

Almost half of adult cancers are diagnosed at a late stage.

Question 2

How do patients arrive at a diagnosis?

Answer 2

Patients arrive at diagnosis by different pathways.

Question 3

What are the pathways for diagnosis?

Answer 3

1. Symptoms: May be specific (e.g. enlarged lymph nodes) or non-specific (e.g. weight loss, anorexia).
2. Screened: A test given to a person with no symptoms (e.g. Pap smears, FIT, PSA tests, mammograms).
3. Incidental: Picked up whilst investigating another symptom.

Question 4

How are cancers diagnosed?

Answer 4

Cancers are diagnosed by:
1. History taking & Clinical examination.
2. Imaging (e.g. X‐rays, CT scanning, US).
3. Less often, blood tests (cancer biomarkers).

Most cancers require histological confirmation/assessment before treatment is initiated.

Question 5

What is required to be 100% sure of a cancer diagnosis?

Answer 5

A Tissue biopsy and histological assessment of the tissue.

Question 6

How do we get to the decision to biopsy?

Answer 6

History taking.

Question 8

How does cancer impact more than health?

Answer 8

It affects all aspects of a patient’s life, including work/school, relationships/friendships, and finances.

Question 9

Who does a cancer diagnosis affect?

Answer 9

A diagnosis of cancer affects the patient but also friends and family.

Question 10

What are key features of good cancer care?

Answer 10

Holistic care of the patient and family are key features.

Question 11

Which age group has the highest incidences of cancer in the UK?

Answer 11

People aged 85-89.

Question 12

Which cancers account for more than half of all new cancer cases?

Answer 12

Breast, prostate, lung, and bowel cancers.

Question 13

When are adult cancers normally diagnosed?

Answer 13

Almost half of adult cancers are diagnosed at a late stage.

Question 14

How do patients arrive at a cancer diagnosis?

Answer 14

Patients arrive at diagnosis through symptoms, screening, or incidental findings.

Question 15

What are common symptoms that might suggest cancer?

Answer 15

Change in bowel or bladder habits, a sore that does not heal, breast lump or thickening, indigestion or difficulty swallowing, extreme fever with night sweats, and unusual bleeding.

Question 16

What are cancer signs on examination?

Answer 16

Lumps, ulcers that aren’t healing, abdominal distension, nodal masses, and DVT.

Question 17

What do symptoms of cancer vary depending on?

Answer 17

Symptoms vary depending on the stage of cancer.

Question 18

What are major presenting symptoms of lung cancer?

Answer 18

The most common symptoms can indicate the advancement of the diagnosis.

Question 19

What history should be explored if lung cancer is suspected?

Answer 19

Explore smoking and occupational exposure, and characterize the symptoms.

Question 20

What should be looked for on examination when lung cancer is suspected?

Answer 20

Signs of metastatic disease, local spread, ectopic hormone production, and non-specific cancer-related symptoms.

Question 21

What should be explored in the history when colon cancer is suspected?

Answer 21

Family history, characterizing presenting symptoms, and asking directly about expected symptoms.

Question 22

What are major presenting symptoms to ask about for colorectal cancer?

Answer 22

Change in bowel habits, blood in stool, abdominal discomfort, and unexplained weight loss or anemia.

Question 23

When does diagnostics come in for cancer?

Answer 23

Diagnostics are ordered after history and examination to find out if the patient has cancer.

Question 24

What are the imaging modalities for cancer diagnosis?

Answer 24

Ultrasound, CT scan, MRI scan, and radioisotope scans.

Question 25

What are the types of tissue biopsy?

Answer 25

Core biopsy, fine needle biopsy, and surgical biopsy.

Question 26

What do tumor markers via blood tests indicate?

Answer 26

Markers like alpha-fetoprotein, CA125, CA15-3, CA19-9, CEA, hCG, and PSA are indicative of various cancers.

Question 27

What are the benefits of early diagnosis of cancer?

Answer 27

Early diagnosis improves outcomes.

Question 28

What are the WHO steps to early diagnosis?

Answer 28

Increasing patient awareness, providing access to clinical evaluation, and ensuring access to treatment.

Question 29

How can we encourage early diagnosis?

Answer 29

Through national screening programs, early recognition of symptoms, and rapid referral to diagnostics.

Question 30

What are the cancer waiting times in the UK?

Answer 30

Performance standard should be 93% for a 2-week wait, with treatment starting within 31 days after referral.

Question 31

What are the cancer weighting times in the UK?

Answer 31

Performance standard should be 93% for a 2 week wait. In 2014/15, the performance was above average at 94.2%. Once a patient has been sent to a specialist and investigations have started, the receipt of first treatment should be within 31 days and 62 days from the first referral. However, for the most part, we are not meeting these targets in the UK.

Question 32

Why is it important to have early diagnosis of cancer?

Answer 32

Early localized disease can often be ‘cured’ by surgery or radiotherapy. The key problem of modern oncology is the treatment of metastatic disease, which requires a systemic approach such as chemotherapy, targeted therapy, or immunotherapy. Focusing on treatment of advanced disease rather than screening and prevention increases the cost of cancer care to health systems.

Question 33

What must we determine before treatment?

Answer 33

We must determine the extent of the disease, known as **staging**. This identifies the size and site of the primary tumor and the extent of metastatic disease, categorizing patients into groups according to their disease extent. This provides important information for prognosis and planning treatment.

Question 34

What are the stages of colorectal cancer?

Answer 34

Stage 1: cancer in situ – cancer just found in mucosa. Stage 2: Cancer through the mucosa and into the muscularis. Stage 3: Through muscularis but not reaching lymph nodes. Stage 4: Breaking through muscularis and spreading to lymph nodes.

Question 35

Describe the TNM staging system.

Answer 35

**T ‐ size of the primary tumour:** T1= invades mucosa, T2= invades muscularis propria, T3= invades to subserosa, T4= invades other organs. **N ‐ status of lymph node metastases:** No= no node metastasis, N1= 1‐3 pericolic nodes, N2= > pericolic nodes, N3 = vascular trunk nodes. **M ‐ presence or absence of metastases:** Mo = no metastasis, M1= distant metastasis. **G ‐ the histological grade of the tumour.** TNM staging allows a standardized language to describe the stage of cancer, but it is not uniform across all cancers.

Question 36

What are the treatment modalities for cancer?

Answer 36

The main treatment modalities are Surgery, Radiotherapy, and Chemotherapy, which includes cytotoxic drugs, small molecule targeted drugs, and immunotherapeutics.

Question 37

What is the aim of cancer treatment?

Answer 37

The aim can be curative or palliative, allowing for the best quality of life (QOL). This is based on the type and stage of the cancer and requires a multidisciplinary team (MDT).

Question 38

What is the concept of adjuvant chemotherapy?

Answer 38

1. Neo adjuvant: starting chemotherapy prior to surgery/radiotherapy to shrink a tumor or create a smaller field for radiotherapy. 2. Surgery/radiotherapy to deal with bulk disease. 3. Follow up with adjuvant chemotherapy to address any residual low volume disease either locally or metastatically.

Question 39

Describe the systemic treatments for cancer.

Answer 39

**Conventional cytotoxic agents:** e.g. cis‐platinum, doxorubicin, 5‐Fluorouracil, target rapidly dividing cells but are relatively non‐specific. **Targeted agents:** aim to reduce toxicity while retaining efficacy, often paired with a biomarker for personalized medicine. **Immunotherapies:** include monoclonal antibodies, checkpoint inhibitors, oncolytic vaccines, and CAR‐T cell therapy.

Question 40

What is stratified/personalized medicine?

Answer 40

Stratified/personalized medicine aims to provide the right treatment for the right patient by identifying the genetic lesion to which the tumor is addicted.

Question 41

What is an example of personalized medicine?

Answer 41

The national lung matrix trial involves biopsying patients with lung cancer at diagnosis and screening tumors for molecular targets. Patients start with conventional cytotoxic chemotherapy, and if it fails, they enter a trial targeting specific molecular signatures.

Question 42

What does cancer impact other than health?

Answer 42

Cancer affects all aspects of a patient’s life, including work/school, relationships/friendships, and finances. A diagnosis impacts not only the patient but also friends and family, highlighting the importance of holistic care.

Question 43

What is involved in palliative care?

Answer 43

Palliative care focuses on 'adding life to days when we can’t add days to life.' It aims to manage patients right up to a good death, ensuring they are well managed and pain-free.

Question 44

Describe what's involved in multi-faceted palliative care.

Answer 44

Multi-faceted palliative care includes skilled symptomatic treatment for issues like pain and nausea, good communication with straightforward information, and ensuring the patient remains in control of their life for as long as possible.