MANAGEMENT OF CANCER Dr.

Lim
Approach to Cancer Diagnosis and Staging kelan ba talaga nag start yung mga signs and symptoms of the cancer
 Diagnosis of cancer is a life altering event You also get the past medical history bc this may alert you as to the
 Its a very traumatic and revolutionary event because when we are presence of other disease which could affect the choice of therapy
healthy, sometimes we take our health for granted. With cancer,
suddenly, materialistic things wont mean anything anymore A. Social hx
 The people around you look at you differently. Its like you are  Smoking and alcohol most common
disabled.  Occupational exposure
 The patient may feel betrayed by their own body. Cancer cells starts
from a normal cell that has divided and produced a mutated cell. B. Family hx is impt
 Cancer is like an autoimmune disease wherein your own body is  Ask if there is a relative with colon ca. Kasi pag meron, all
traitorous to your own body the siblings na lalake should undergo colonoscopy
 The usual age to do colonoscopy is 50yo
 But if your patient is a colon ca patient, 40yo, you subtract
The most common cancer in terms of incidence 10 from his age kasi yun ung age na ung mga relatives or
 Male: prostate siblings, kelangan magpa colonoscopy
 Female: breast
 Lung cancer is second in both sexes C. Review of Systems
 This could give you an idea as to the stage of the patient
Most common cancer in terms of mortality  Eg: lung ca --> with severe headache and dizziness --
 Most common is lung cancer in male and female >Possible Brain metastasis
 Second most common is prostate and breast cancer  Do cranial mri to check if there is any metastasis to the brain
D. Physical Exam
The most significant risk factor of cancer as a whole is age  ecov or ps should be included when getting the vital signs in
 From birth up to 39yo a cancer patient
o 1 in 70 men will develop cancer
o 1 in 48 women will develop cancer  Diagnosis of cancer is usually through biopsy. Even if its
already a sure case of cancer, you should still do a biopsy bc
 60-79yo this can be a legal issue.
o 1 in 3 in men  No non invasive diagnostic test is sufficient to define a
o 1 in 5 in women disease process such as cancer.

Overall, Men have a 44% risk of developing cancer at sometime during Types of biopsy
their lives while women have a 38% lifetime risk a) Core needle
– the one that we like. Bc if you look at the management of
Know the 5 leading primary leading tumor sites for pxs dying if cancer breast cancer, its no longer just giving chemotherapy.
BOOK!! – To know if the patient is Er + the test is being done on the
specimen of the tissue that is obtained by the surgeon.
 All ages, most common ca mortality lung ca – The needle is a bit bigger than the fnab but the specimen
 Under 20yo, leukemia is the most common in male and female obtained is enough for the test.
 20-39yo
o leukemia mostly in males b) Fnab –
o breast ca most common in females – its just aspiration, you cannot perform er, pr & her2
 F 20 -59 yo breast is the most common staining test in the specimen.
 60-79 and >80 yo most common is lung cancer – Mahirap kasi when you subject the patient to fnab, then
afterwards malignant pala, then you ask them to undergo
Management of Patient with Cancer core needle type, thats very traumatic for the px so just ask
 Starts with diagnosis the px to go straight to core needle
 History and PE is important – Cases where you could do fnab  Thyroid nodules

If you have a patient and you're thinking of a malignancy, obtain a good c) Excision
history and pe, ask for the duration of the symptoms to know kung d) Incision

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MANAGEMENT OF CANCER Dr. Lim
– Unable to carry out normal activity or do
Eg: In lung ca biopsy, the usual is that we do ct scan guided biopsy so active work
the px is subjected to ct scan and then they put a marker where the  60 - requires occasional assistance
tumor is and then they insert a needle while the px is inside the ct scan
machine tapos kukuha sila ng sample. The needle is equivalent to the
gauge of the core needle used in breast ca  Ecog
 limit is usually grade 2
If not ct scan guided biopsy, another way to obtain a lung tissue is  Grade 3 - already confined to bed or chair for more
through bronchoscopy --> Insert scope --> Bronchoscopy machine has than 50% of the waiting hours
a err thing that gets a tissue sample – we do not give iv chemo just the tablet
 Ecog is corresponding with karnofsky
Once the diagnosis is made, its important that there should be  70kps = grade 2 ecog
collaboration between different doctors. Usually, in cancer, its usually a  If <70 or ecog 3, we do not give chemo
combination of
 medical oncologist - dx and giving chemo
 surgical oncologist-operating
 radiation oncologist - gives radiation
 and nurses.

Once you have the dx of the patient, the next step is to determine the
extent=stage. We need to know the stage of the patient so that it could give
us an idea as to the prognosis. The higher the stage, the higher the
prognosis. The curability of a tumor is inversely proportional to the tumor
burden. So the higher the stage, the more the tumor burden, the lesser the
chance that the patient can be cured. Ideally we want to diagnose the
patient in an early stage but in real practice, most of the patience are in
stage 3 and 4.

There are 2 types of staging

 Clinical - manifestations and ct scan xray, cytoscopic scan
 Pathologic - when the patient undergoes biopsy or an operation

For example in colon cancer, when they do a colonoscopy and they get a
biopsy it is not enought for staging. We usually wait for the section, pag
inalis na ung colon, ung part na tinanaggal dadalhin sa pathologist for them
to look at the layers of intestine so kung gano kalalim yung depth of the
tumor, that is already your T.
To know the M, you need pathologic staging. The surgeon, when he resects
the intestine with the tumor, he will also get lymph nodes. The required
number of lymph nodes that should be harvested is around 14 lymph nodes.
That will also be sent to see if theres a metastasis. If - yung ln, then thats an
early stage, usually stage 2. If + stage 3.

Ct scan or imaging will not be able to tell you whether the lymph nodes has
spread of cancer or not. It is usually through pathologic staging.

TNM staging - most ca use this

T tumor size
N nodal involvement
M metastasis

Other cancers will have their own staging. Hodgkins disease ann arbor
staging
Ovarian and cervical ca we usually use the freego? Or International
federation of gynecologists and obstetricians classification

Determinants of treatment outcome

There are 2 ways for us to know if the patient will have a good prognosis
or good response to the treatment or not. Tumor markers are used to look at the prognosis of the patient and to
 We look at the tumor burden - the higher the tumor burden, the monitor the chemotherapy response
poorer the prognosis a) Afp - liver ca, testes
 Physiologic reserve – eto yung sinasabi nating ECOG & Physiologic b) Bhcg - testes testicular ca seminoma and gestational trophoblastic dse
status c) Cea - colorectal ca
 We look at the patient. Is he ambulatory? Bedridden? Weak? d) 15-3 - breast
Strong? They found that for patients who are weak and e) 19-9 - pancreas
bedridden, if you give chemo, if will further cause the f) 125 - ovary
deterioration of the patient. g) Psa - prostate
h) Thyroglobulin - thyroid
 Karnofsky performance status
 Our limit for giving chemo is 70
 If lower than 70, we don't give chemo
 70 - cares for self

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MANAGEMENT OF CANCER Dr. Lim
MANAGEMENT  Prophylactic
There should be coordination between doctors  Diagnostic
 Staging
Two goals in cancer treatment  Tx
 Eradicate or cure the cancer - early stages  Palliation
 Palliation - stage 4  Rehabilitstion

Surgery, radiation therapy, chemotherapy are used hand in hand in treating Eg: persons na nagpabilateral mastectomy, a surgeon can undergo
cancer reconstruction
Local therapy - is surgery and radiation therapy Those women some of the are depressed because they feel like they are
Not all cancer can be treated with this disfigured so you can do breast reconstruction to help them gain
confidence.

Chemotherapy Those with osteosarcoma, naamputate ung paa--> Use prosthesis to walk
 Systemic
 Biologics Radiation therapy
 Radiation is the use of laser.
New drugs are falling under the biologic agents  A laser is pointed, focused or beamed to the area of the tumor and
Eg. Avastin for colon ca the mechanism of action is dna breakage of the tumor cells. Inside,
the cancer cells will die or undergo necrosis
 Can be used in conjunction with chemotherapy to treat certain
Gompertzian growth curve cancers
 Growth fraction of a neoplasm starts at 100%  It can also be used to palliate symptoms --> Patients with bone mets
 Habang tumatagal, bumababa muna yung number of cancer cells and that are unresponsive to pain relievers --> You can use radiation to
then suddenly, there will be a spurt and then at the time of diagnosis, ease the pain
the tumor burden is usually 10^9  Kasi ang nag ccause ng bone pain is kinakain ng tumor cell ung bone
 The clinically detectable is 10^9 what you do is aim the rad beam to kill the ca cells thats eating the
 The lethal/ host death will happen when the cells reach 10^12 bone to relieve bone pain
 Spinal cord compression
Surgery  In cases of high risk setting we do prophylactic radiation of the brain
 Can be used to diagnose, stage, treat, or for palliation and for example, breast ca, high risk for brain mets pwede nyong unahan
rehabilitation at bigyan na ng rad therapy
 Can either be used for prophylaxis in patients with a high risk in  Photodynamic therapy - when the patient is placed under the
developing cancer machine and there is a laser pointing to the tumor
 May remove a part of the body if its a very high risk to develop cancer  Brachytherapy - a seed is inserted to the area of the tumor usually
 Can also be used for diagnosis used for cervical cancer, so ipapasok sa cervical area and then slowly
 Excisional mag eemit ung seed ng radiation the problem is you cannot control
 Incisional kung saan tumatama or kung sino ung mga tissues that are being
 Core needle usual used except if maliit lang ung bukol sa breast and if exposed to the seed so nagkakaroon ng effect sa mga normal tissue
you do excisional, it can be therapeutic bc you already remove and surrounding the cancer and you may have cystitis or enteritis -->
then it can also be diagnostic bc u can send the tumor for diagnosis recurrent infection of the bladder
 Fnab
 Surgery - Can also be used for pathologic staging by removing lymph Radiation therapy toxicities
nodes 1) Acute toxicities
 As treatment  N and v
 If a cancer patient has a small tumor which can be subjected to  Fatigue
surgery, surgery still offers the best chance of cure -- however this is  Anorexia
only applicable for early stage cancer  Mucositis
 Pag meron ng kalat sa lymph nodes, surgery is not enough. You will  Skin erythema
need other forms of tx  Bone marrow toxicity

The current trend is combination o Bone - radioresistant

 Pag masyado kasing malaki ung bukol, pag inoperate, hindi masasarsa
yung chest kasi ung skin masyadong malaki ung inalis na bukol hindi
nila macclose.
 And then pwede ding pag inopera kaagad, napakalaki ng bukol, may
maiwan so that can be a cause of recurrence
 Some patients are usually referred to oncologists for chemo pars
paliitin muna ung bukol before they remove it
 Head and neck ca is rarely advised to undergo surgery
Eg px smoke male, broadcaster, pos laryngeal ca
We usually do radiation and chemo instead of surgery
Palliation
 Surgery can also be used to palliate
 Eg if px is bedridden, di makakain, surgeons can put a bypass para to
make sure that the nutrition of the patient is addressed
 splenectomy for patients with hypersplenism
 Intrathecal or intrahepatic catheter? for infusion portals
Roles of surgery
o Heart, skeletal muscle & nerves - resistant
o We do not usually subject the heart to radiation kasi you might
cause heart failure
o Testes, ovary and bone marrow are the most sensitive organs
including the mucosal lining of the intestines
2) Chronic toxicities
 Cataract and retinal damage
 Head and neck cancer  halitosis  bc salivary gland gets
exposed to radiation  burn  dry mouth  no production of
saliva dental caries and poor dentition
– Sometimes, taste and smell can also be affected
 The worse chronic toxicity is development of a second
malignancy.
– Eg in women who had Hodgkin's dse and has
undergone radiation, if they received radiation at 25
yo, there is a 30% risk that they will develop breast ca
by the age of 55

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MANAGEMENT OF CANCER Dr. Lim
Chemotherapy - eg doxurubicin, paclitaxel, docetaxel
 There are 4 broad types
1) Progressional ?
2) Hormonal - eg. tamoxifen and aromatase inhibitor
3) Targeted - eg. herceptin, avastin, herbitux,
4) Biologic - eg. tyrosine kinase inhibitors

Book rememberrrr!!! first 5

Advanced cancers with possible cure,
by chemo and rt, with chemo as adjuvant of surgery,
ca possibly cured with high dose

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MANAGEMENT OF CANCER Dr. Lim
 Cytosine arabinoside
Different types of response  Azacytidine
 Partial response - a decrease by 50%.  Gemcitabine
– Eg. Brfore we do chemo, we do ct scan so that we have a  Fludarabine phosphate
baseline size of the tumor. After giving chemo, we again do ct  Asparaginase
scan and then we look at how much the tumor shrinked in size  Pemetrexed
 Complete response - lahat ng tumor nawala. Shrinks totally
 Progression - there is an increase in size by more than 25% from Antimitotic Agents
baseline  Vincristine
 Stable disease - does not fit any of the mentioned definition. Tumor  Vinblastine
did not increase or decrease in size after chemo  Vinorelbine
 Paclitaxel
Neoajduvant  Docetaxel
 is chemo given before surgery to shrink tumor before operation  Estramustine phosphate
 the primary goal is to shrink the tumor
 Nab-paclitaxel (protein bound)
 Ixabepilone
Adjuvant
 is chemo given after surgery
Molecularly Targeted Agents
 the goal is to prevent recurrence
Retinoids
 The purpose is to kill whatever tumor cells ang naiwan sa system
 Tretinoin
 Bexarotene
Concurrent chemo
 chemo is given together with another (eg. radiation therapy ) for
Targeted Toxins
treatment, usually used in head and neck ca
 Denileukin diftitox
Palliative
 usually in patients who are stsge 4 Tyrosine Kinase Inhibitors
 Imatinib
Chemo agent  Gefitinib
 Erlotinib
BOOK!!! KNOW WHAT CLASSIFICATION THE DRUGS BELONG TO
 Dasatinib
 Sorafenib
Direct DNA-Interacting Agents
Alkylators  Sunitinib
 Cyclophosphamide
Proteosome Inhibitors
 Mechlorethamine
 Bortezomib
 Chlorambucil
 Melphalan
Histone Deacetylase Inhibitors
 Carmustine (BCNU)
 Vorinostat
 Lomustine (CCNU)
 Romidepsin
 Ifosfamide
 Procarbazine
mTOR Inhibitors
 Dacarbazine (DTIC)  Temsirolimus
 Temozolomide  Everolimus
 Altretamine (formerly hexamethylmelamine)
 Cisplatin Miscellaneous
 Carboplatin  Arsenic trioxide
 Oxaliplatin
Cell cycle
Antitumor Antibiotics and Topoisomerase Poisons  Second important thing in basic onco
 Bleomycin  Used by normal cells and ca cells to multiply
 Actinomycin D  Resting g0
 Etoposide (VP16-213)  Preparatory g1 and g2
 Topotecan  Active s and m
 Irinotecan (CPT II)
 Doxorubicin and daunorubicin Doxorubicin + docetaxel common combination for breast cancer
 Idarubicin  Doxo acts on s phase of the cell cycle
 Epirubicin  Docetaxel and paclitaxel acts on the m phace of cell cycle
 Mitoxantrone  The reason for combination chemo is that bc sometimes, the cancer
cell can still develop resistance or mskakaescape ng action ng doxo
Indirect DNA-Interacting Agents kaya makakaproceed ng g2 so if you have another drug, the drug will
Antimetabolites again kill the cancer cells in the mitosis phase
 Deoxycoformycin
 6-Mercaptopurine Tyrosine kinase inhibitors
 6-Thioguanine  Imatinib used for gist
 Azathioprine  Gefitinib And erlotonib both are used for lung ca
 2-Chlorodeoxyadenosine  Lapatinib used for breast ca
 Hydroxyurea  Soritinib and soratonib is used for kidney cancer
 Methotrexate  Soratonib alone is used for liver csncer
 5-Fluorouracil (5FU)
Tyrosine kinase inhibitors
 Capecitabine
 work by binding to the receptor preventing growth factors produced

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MANAGEMENT OF CANCER Dr. Lim
by cancer cells from binding to the receptor. Tumors produce growth
factors, the growth factors, if they bind to your receptors, it will cause
signaling, the endpoint is that it will cause angiogenesis, growth of ca
cells, metastasis
 They prevent it from happening by:
 going to the receptor and bind there para di na maka bind ung
ibang growth factor
 Intracellular kahit na maka bind ung growth factor, the drug
will go to the inside of the cell and prevent phosphorylation so
tumor cells cant proceed to signaling

Common complications of chemo

Acute
 Myelosupression - low white count, rbc and platelet
 Febrile neutropenia - either 1 reading of 38.5 degrees c or 3 readings
of 38c in a neutropenic patient with an uncontrolled neoplasm or
underwent chemotherapy
– Remember that the neutropenia occurs 6-14 days after
chemo, drop in the wbc, admissible to the hospital
– Tx. Give an injection of granulocyte colony stimulating factor
G-CSF, in a form of a vial/syringe and inject sq
– Indication for giving G-CSF is that if the chemo drug has a
>20% risk of a px having neutropenia
 Alopecia
 N and v
 Diarrhea
 Erythema
 Dyschromia - the number of lines in the nails will tell you how many
cycles of chemo the px has received
 Hand and foot pruritus
 Rash
 Stomatitis - usually give mouthwash bc its v painful --> related to the
white count pag mababa un white count, prone to fungal and
mucositis infection
 They can develop hand and foot reaction, ulceration,
 These toxicities are usually seen in tablet drugs

Approach to Cancer Diagnosis and Staging

 Diagnosis of cancer is a life altering event

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SHAY