Primary care presentations Flashcards
T/F When relevant, cancer should
always be in your differential
T
3rd leading cause of cancer and cancer deaths in both men and women
(Incidence and death rates have dropped significantly in the last 30 years)
Colon cancer
Colon cancer incidence
● 149,500 cases in the US in 2021
● 52,980 deaths in the US in 2021
Most colorectal cancer arises from _____
adenomatous polyps
Colon cancer risk factors
○Lifestyle – diet high in fat, obesity, tobacco use
Hereditary syndrome
○ Familial polyposis of the colon (Polyposis coli)
○ MYH-Associated Polyposis (MAP)
○ Lynch Syndrome – Hereditary Nonpolyposis Colon Cancer (HNPCC)
Inflammatory bowel disease
Streptococcus bovis
Hereditary Nonpolyposis Colon Cancer (HNPCC)
Lynch Syndrome
Colon Cancer risk reduction
○ ASA
○ Estrogen replacement (risk/benefit)
○ Vit D (promising, still under study)
Prevention for colon cancer
○ Colonoscopy
■ Removal of adenomatous polyps
before they become cancerous
■ Detect cancer early
Colon Cancer S/S - Ascending
● Less formed stool
○ More likely asymptomatic
○ Less likely to feel obstruction or have
change in bowel habits
● Fatigue, palpitations
● Chronic blood loss → Microcytic anemia
indicative of iron deficiency
● Weight loss (later stages)
Colon cancer S/S - Descending and Sigmoid
● More formed stool as it progressives through colon
○ Impede stool → cramping, bowel
obstruction
● Narrow stool
● Hematochezia
● Tenesmus
● Weight loss (later stages)
Colon Cancer - Diagnosis
(patient with symptoms)
○ Fecal occult blood
○ Colonoscopy (Gold Standard)
■ Biopsy
○ Barium enema (may be considered)
Colon Cancer staging
○ TNM classification
○ CT Chest/Abd/Pelvis
○ Genomic studies and DNA Sequencing
Colon Cancer Treatment
○ Treatment and prognosis are based on staging
○ Carcinoembryonic antigen (CEA) Level (tumor marker)
○ CT Chest/Abd/Pelvis
○ Surgical resection – Attempt at total resection
■ Early small non-invasive malignant polyps may be removed with
colonoscopy, but must have clear margins
○ Radiation therapy
○ Chemotherapy – 5-fluorouracil prior to surgery
○ Monoclonal antibodies – cetuximab and panitumumab
Leading cause of female cancers
Breast cancer
Breast cancer incidence
● 281,550 cases in the US in 2021
● 43,600 deaths in the US in 2021 (decrease by > 1⁄3 in last decades)
Breast Cancer - Risk factors
○ Age over 50
○ Familial risk – 1st degree relative
○ Gene Mutations – BRCA1 and BRCA2
○ Hormone-dependent (early menarche, later first pregnancy)
○ Obesity
○ Moderate alcohol intake
○ Chest radiation before age 30 yrs
Breast cancer risk reduction
○ Avoidance hormone replacement (HRT)
○ Early menopause
○ Duration of maternal nursing (longer is better)
Breast cancer prevention
○ Self awareness – rather than regular breast exams
○ Screening mammograms/MRI
○ Tamoxifen and raloxifene used for
chemoprophylaxis in high risk*
○ Prophylactic mastectomy – high risk individuals
Breast cancer S/S
○ Breast mass/nodule (document size and location) - more likely to be painless
○ Dimpling
○ Skin changes “peau d’orange”
○ Nipple discharge or retraction
○ Enlargement or shrinkage of the breast
Breast Cancer Diagnosis
○ Diagnostic mammogram (not the same as screening)
■ Takes longer, varied angles, magnification of area of concern
○ Additional imaging usually for higher risk
■ Targeted breast U/S
■ MRI (High sensitivity, but not specific → increased biopsies)
○ Breast biopsy
Breast cancer staging
○ TNM classification
○ Genetic test and DNA sequencing with specific gene expression
Breast cancer treatment
○ Based on staging and gene expression
■ HER2, ER, PgR
○ Surgical – lumpectomy, partial or complete mastectomy, etc
○ Radiation
○ Systemic treatments
■ Hormone Therapy (selective estrogen-receptor modulators “SERM”)
■ Anti-HER2 – monoclonal antibodies (Herceptin)
■ Chemotherapy
Leading cause of cancer deaths in the US and Europe
Lung cancer
Lung cancer incidence
● 235,760 cases in the US in 2021
● 131,880 deaths in the US in 2021
Increased rates in minority populations – Black, Hispanics, Asian
Lung cancer Highly associated with ____ use (known since the 1960s)
tobacco
Lung cancer screening
○ Adults 50 to 80 years with 20 pack-year smoking history and
currently smoke, or have quit within the past 15 years
■ Low-dose computed tomography (CT) every year
○ Stop screening once a person has not smoked for 15 years or has
a health problem that limits life expectancy or the ability to
have lung surgery
○ Grade: B
Lung cancer risk factors
○ Cigarette smoking (greater than a 10 fold increase)
■ Former smokers are at reduced risk compared to current smokers
○ Second-hand smoke
○ Asbestos, arsenic, chemical exposure
○ Low fruit and vegetable intake
○ Ionizing radiation
○ Chronic lung disease – TB, emphysema
○ Certain inherited genetic traits may be a factor
Lung cancer S/S
○ Cough 8-75%
○ Weight Loss 0-68%
○ Dyspnea 3-60%
○ Chest pain 20-49%
○ Hemoptysis 6-25%
○ Fever 0-10%
○ Weakness 0-10%
Lung cancer Findings Suggestive of Metastasis
○ Weight loss > 10 lbs
○ Neurological – HA, syncope, seizure,
altered mental status
○ Bone pain
○ Lymphadenopathy (SVCS)
○ Hoarseness
○ Pancoast tumor
○ Papilledema
○ Malignant pleural effusion
___ (tumor of the lung apex) can
cause pain down the arm in an ulnar
distribution, and can cause Horner syndrome
Pancoast tumor
Horner Syndrome
○ Sympathetic nerve palsy
■ Enophthalmos
■ Ptosis
■ Miosis
■ Anhidrosis
Lung Cancer diagnosis
○ Imaging – CXR, CT, MRI
○ Sputum cytology – low yield
○ Biopsy – bronchoscopy, percutaneous image
guided FNA
■ Type of cancer based on morphology and cytology
Lung Cancer - Four major types
■ Small Cell Carcinoma: Common with tobacco use, more aggressive
■ Large Cell Carcinoma
■ Squamous Cell Carcinoma: Common with tobacco use
■ Adenocarcinoma: More common as smoking rates have decreased
Lung Cancer Staging
○ TNM classification – ie. lymph node sampling, metastatic spread, etc.
○ “Physiologic staging” – Tx tolerance? Consider comorbidities
○ Genetic testing and DNA Sequencing
Lung Cancer Treatment – NSCLC
○ Surgical resection
○ Radiation and/or chemotherapy if more advanced
○ Immunotherapy based on specific gene expression
■ T cells become active against tumor cells
Lung Cancer Treatment – SCLC
○ More highly aggressive form of cancer, high relapse potential
○ Chemotherapy and/or radiation as first line
○ Surgery is not often indicated
Most common gynecologic malignancy
Uterine cancer
Uterine cancer incidence
● 66,570 cases in the US in 2021
● 12,940 deaths in the US in 2021
Different types of tumors of the uterus
○ Benign – uterine fibroid (leiomyoma)
○ Malignant (leiomyosarcoma)
■ Most (80%) are endometrial adenocarcinomas
Uterine cancer Risk Factors
○ Obesity
○ Postmenopausal estrogen treatment
○ Lynch Syndrome
○ Long-term use of Tamoxifen
Tamoxifen BBW
Tamoxifen antiestrogenic in the breast but is associated with weak estrogenic effects in uterine epithelium→ increased risk of endometrial cancer
Uterine cancer S/S
○ Postmenopausal bleeding
○ Premenopausal women – atypical bleeding between cycles
○ Pelvic mass…with or without bleeding
○ Pelvic pain (+/-)
Uterine cancer Diagnosis
○ Imaging – Ultrasound
○ Biopsy – endometrial biopsy w/o or
w/ Hysteroscopy
Uterine cancer staging
○ TNM
○ 75% of disease is localized to the
uterus (Stage 1)
○ Genetic testing – Lynch
Uterine cancer treatment
○ Hysterectomy with removal of
ovaries and fallopian tubes
■ Stage 1
○ Chemotherapy for later stages
■ Node involvement
○ Immunotherapy
Two main categories of lymphoma
○ Hodgkin’s Lymphoma
○ Non-Hodgkin’s Lymphoma
Lymphoma Risk Factors
○ Epstein Barr, HHV-8, HTLV-1
○ H. pylori and MALT
○ Acquired or inherited immunodeficiency – HIV (17x higher)
○ Autoimmune diseases
○ Organ transplant
____ _ is bimodal peak at 20’s and 50’s +, enlarge lymph node
typically found in upper body, presence of _____ , easier
recognize and treat
Hodgkins; Reed-Sternberg Cells
_____ rates rise with age >40, but still common in children and
young adults, depending on the type, arise anywhere in the body, less
predictable, harder to treat
Non-hodgkin’s
T/F Non-hodgkin’s is easier to treat
F
Lymphoma S/S
○ Painless, firm, “rubbery” lymph nodes
■ May become painful after alcohol consumption
○ Fatigue
○ Pallor
○ Fever
○ Night sweats
○ Hepatosplenomegaly
○ Generalized pruritus
Lymphoma Diagnosis
○ Imaging – U/S, CT
○ Excisional biopsy
○ Bone marrow biopsy
Lymphoma Staging
○ Varies based on type – DNA analysis
○ Blood levels – Peripheral blood blast counts and Lactate dehydrogenase,
etc
Lymphoma Treatment
○ Chemotherapy
○ Bone marrow transplant
○ Immunotherapy
○ Surgery if indicated (based on type)
Lymphoma monitoring
○ Imaging – PET/CT, CT, MRI
○ Possible bone marrow or tissue Bx (depending on cancer involvement)
