Week 4 Flashcards
Epidemiology ovarian cancer
Incidence- around 160000 new patients/year worldwide
Mortality is high- at best 30% 10 year survival
What do i need to know
1 in 2 adults will be diagnosed with cancer in lifetime
Large national screening programs- cervix, lung, breast, colorectal
Multiple specialities involved in cancer care- radiology/laboratory medicine/ surgery/ oncology/pain/palliative care/community care
Cancer contributes to multimorbidity
Cancer impacts more than health
It affects all aspects of a patients life
-work/school
-relationships/friendships
-finances
A diagnosis of cancer affects the patient but also friends and family
Holistic care of patient and family are key features of good cancer care
Basic uk facts on incidence
~375000 new cases of cancer/year
-36% are diagnosed in people ages 75 and over
-incidence rates for all cancers combined in the UK are highest in people aged 85 to 89
-estimated around 506000 new cases of all cancers combined every year in the UK by 2038-2040
Uk incidence is ranked higher than three quarters of Europe
Uk incidence is ranked higher than 90% of the world
Breast, prostate, lung, bowel cancers together accounted for more than half of all new cancer cases
Basic UK facts on mortality and survival
167142 deaths/year
-lung, bowel, breast and prostate cancers together accounted for almost half of all cancer deaths (~20% lung cancer)
-accounts for 1 in 4 deaths in the UK (2017)
-cancer causes more than one in four of all deaths 2020 UK
On average 50% of patients diagnosed with cancer survive over 10 years
-cancer survival in the UK has doubled in the last 50years
-survival rate dependent on cancer type; range 1-98%
worldwide cancer picture
There were 18.1 million new cases of cancer worldwide in 2020 it is estimated
Estimated 10 million deaths
A third contributed to by smoking
The 4 most common cancers occurring worldwide are female breast, lung, bowel and prostate cancer- more than 4 in 10 of all cancers diagnosed worldwide
Lung, bowel, liver and stomach are the most common causes of cancer death worldwide- more than 4 in 10 of all cancer deaths
Almost half of adult cancers are diagnosed at a late stage
Patients arrive at diagnosis by different pathways
Symptoms: may be specific to one cancer eg enlarged lymph nodes, may be non-specific eg weight loss, anorexia
Screened: a test given to a person with no symptoms of a disease- eg PAP (cervical) smears, FIT, PSA tests and mammograms
Incidental: picked up whilst investigating another symptom
Making a cancer diagnosis
Cancers are diagnosed by:
-history and clinical examination
-imaging eg X-rays or CT scanning or ultrasound
-blood tests- cancer biomarkers
Tissue biopsy and histological assessment
Most cancers require histological confirmation/assessment before treatment is initiated
Symptomatic diagnosis common symptoms that might suggest cancer- RED FLAG symptoms
Change in bowel or bladder habits: stomach, pancreatic, colon and ovarian cancers may change the bowel and bladder habits
A sore that doesn’t heal- unusual shape, border and crusts with a foul smelling discharge
Unusual bleeding- blood when passing urine or stools may be a warning sign of kidney, bladder and intestine cancers
Breast lump or thickening: any mass or growth in the breasts sometimes may be painful and contain blood or fluid
Indigestion or difficulty swallowing: a constant feeling of having a lump in the throat or difficulty in swallowing
Extreme fever with night sweats
Persistent cough or hoarseness: with or without chest pain, fatigue and shortness of breath
Examination- signs
Lumps
Ulcers that aren’t healing
Abdominal distension
Nodal masses
DVT
Lung cancer major presenting symptoms
Breathlessness, cough, pain, loss of appetite, coughing up blood
What do we explore in the history when lung cancer is suspected
Smoking and occupational exposure:
-no of cigarettes/day/risk of death from cancer
-chromium, arsenic, asbestos
Characterise the symptoms:
-has anything changed recently
—eg worsening of existing cough
-anorexia, weight loss, extreme fatigue
—indicate advanced (usually unresectable) disease
What do we look for on examination when lung cancer is suspected
Signs of metastatic disease: eg brain, bone , liver
Signs attributable to local spread: eg superior vena cava obstruction, horners syndrome, pancoast syndrome, pleural effusion, lymph nodes
Signs attributable to ectopic hormone production: eg Cushing’s syndrome from ACTH secretion
Non-specific cancer- related symptoms: weight loss and cachexia
What do we explore in the history when colon cancer is suspected
Is there a family history
Characterise presenting symptoms:
-how long
-what’s changed recently , weight
Ask directly about expected symptoms. Blood in motions
Major presenting symptoms colorectal cancer
A change in bowel habits: diarrhoea, constipation
Bright red or dark blood in the stool
Discomfort in the abdomen, bloating and cramps
Unexplained weight loss or anaemia (iron deficiency)
What do we explore on examination when colorectal cancer is suspected
Palpable mass in abdomen
Palpable mass/blood per rectum
Enlarged (lumpy) liver
Imaging modalities
Ultrasound scan
CT scan
MRI scan
Radioisotope scans:
-bone scans
-PET scans
-MIBG scans (neuroblastoma)
Tissue biopsy
Core
Fine needle
Surgical
-percutaneous, or via a ‘scope’.. colonoscopy, bronchoscopy, cystescopy etc
Tumour markers
In standard clinical practice:
-alpha-fetoprotein AFP
-cancer antigen 125 (CA125)
-cancer antigen 15-3 (CA15-3)
-carbohydrate antigen 19-9 (CA19-9)
-carcinogembryonic antigen (CEA)
-human chorionic gonadotropin (hCG or beta-hCG)
-prostate-specific antigen (PSA)
-urinary catecholamines
In experimental development
-circulating tumour cells (CTCs)
-circulation tumour DNA (ctDNA)
Early diagnosis improves outcomes
WHO steps to early diagnosis
-increasing patient awareness and accessing care
-clinical evaluation, diagnosis and staging
-access to treatment
Barriers exists at every step contributing to delays in diagnosis
How can we encourage early diagnosis
National screening programmes
-breast, bowel, cervical cancer screening
Early recognition of cancer related symptoms
-public awareness campaigns
-primary care awareness
Rapid referral and access to diagnostics
Increasing awareness in primary care
Often patients present to GPs with non specific symptoms
Signs of cancer may also not be clear or obvious
An average GP:
-has between 6000-8000 appointments/year
-sees ~8 new cancer cases/year
-has around 10 minutes per appointment to pick out warning signs that could be cancer but equally may be a symptom of a less serious condition
NICE guideline based on symptoms:
-to make its recommendations easier for GPs to use
-recommendations organised by symptoms which should prompt a 2 week wait referral and further investigation in primary care and safety netting in primary care
Cancer waiting times, UK countries
Performance standard should be 93% for a 2 week wait
2014/2015 the performance was above average 94.2%
However once patient has been sent to specialist and investigations have been started then receipt of the first treatment should be within 31 days and 62 days within the first referral
For the most part we are not meeting these targets in UK
Before treatment we must determine the extent of the disease
Staging
Categories patients into groups according to the extent of their disease
Important for:
-prognosis
-planning treatment
Treatment of cancer
Early localised disease can often be cured by surgery or radiotherapy
Importance of early diagnosis
Treatment of metastatic disease- needs a systemic approach- chemotherapy/targeted therapy/ immunotherapy
Cost of cancer care to health systems that focus on treatment of advanced disease rather than screening and prevention and early detection
Staging of colorectal cancer
Stage 1- cancer in situ located in mucosa
Stage 2- through the mucosa and invaded the muscularis
Stage 3- beyond the muscularis of the colon or rectum but has not spread to the lymph nodes
Stage 4- cancer has spread to regional lymph nodes
the TNM staging system
T-size of the primary tumour: T1(invades mucosa), T2(invades muscularis propria), T3(invades 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 tumour
Not applicable to all cancers. Eg haematological malignancies and some paediatric cancers
