Treatment of Cancer - Modalities & Purpose (TG)

Question 1

STATS
People diagnosed with cancer in 2013
Lifetime risk in 2010

Answer 1

350,000

4 in 10

Question 2

What is a key societal reason for the increased lifetime risk / incidence?

Answer 2

Patients are not dying from other organic / chronic diseases

Question 3

How can the risk of cancer in general, be reduced?

Answer 3

Improved diagnosis that is quicker and more accurate, quicker referral and treatment

Question 4

What are the 3 most common cancers?

Answer 4

Prostate / Bowel
Lung
Bowel

Question 5

NHS Cancer Guidelines and Timelines

Answer 5

All patients with suspected cancer should be referred to specialist from the GP within 2 weeks of referral.
Cancer patients should wait no more than 31 days from the decision to treat to the start of their first treatment.
All patients should be seen within 62 days of their urgent GP referral (including from screening programmes)

Question 6

How is cancer diagnosed?

Answer 6

Non-invasive or invasive (BIOPSY)

• minor or major procedure
• least invasive procedure should be used

Cytology

• body fluids; plueral, sputum etc
• tissure scrapings or superficial smear
• fine needle aspiration (easy to miss cancerous cells)

Incision or excision (totally removed) biopsy
- liquid biopsies (new development, DNA excretion or leaching into blood) so a blood sample can be used and may also help to pick up resistant mutations too.

Question 7

How is staging of a cancer determined?

Answer 7

After diagnosis
Define the local and distant extent of the disease
Optima treatment determination from staging
Provides a baseline to measure a response to treatment
Provides prognostic information

Question 8

TNM Staging - what does TNM stand for?

Answer 8

Tumour Node / Metastases
First used in the 1940s
A formalised a universally applied scheme
T= primary tumour
N= regional lymph nodes
M= distant mestases
Each of these categories is assigned a number based on the extent of the disease.

Question 9

What is the staging range and interpretation of TNM staging?

Answer 9

Will be written as T 3 N0 M0 (M is either 0 or 1 based on metastases
Stage 0 - carcinoma in stiu
Stage I-III Higher numbers indicate a more extensive disease (beyond organ)
Stage IV The cancer has spread to distant tissues or organs

Question 10

What is the GRADE of a cancer?

Answer 10

Microscopic assessment of the degree of differentiation which the cells show. Either well differentiated (grade 1) or poorly differentiated (grade 3). Well differentiated tumours are low
Anaplastic - no differentiation, aggressive and very hard to treat

Question 11

What factors affect treatment chosen?

Answer 11

Performance status ; the WHO performance scale measures a patients general health performance
0 all normal activity no restriction
1 mobile and light work
2 mobile and self caring
3 only limited to self care and confined to a bed or chair for >50% of waking hours
4 completely disabled and confined to bed or chair

TNM Stage and Grade

Prognosis

Tumour genetics (EGFR mutation for example)

Co-morbities (hepatic or renal problems)

NICE guidelines (NICE approval may be needed if new and not on the NHS already)

Patient choice

Question 12

What kind of treatment is surgery ?

Answer 12

Invasive Tx
Patient is only treated when the cancer progresses
Surgery may be the only intervention in some early tumours or may be carried out in palliative care to make a patient more comfortable or survive for longer.
It can be very complex with major reconstruction of bone and soft tissue needed.
With radiotherapy pre or post operative

Question 13

What is the role of radiotherapy in treatment?

Answer 13

pre or post operative, or palliative care
not suitable for all tumours
several Tx falls under the radiotherapy category
- external beam RT
- brachytherapy
- radioisotope therapy
Dose and course varies between tumour type and treatment intent

Question 14

What are the steps in external beam RT? +s and -s

Answer 14

Complicated to plan
- MRI to plan tarfet and a planning CT scan
Software used to calculate the dose and beam positioning
Patient remains still
Can be treated as an outpatient

Question 15

What is Brachytherapy?

Answer 15

Radioactive sources placed either in or close to the tumour

• mould treatment
• intra-cavitary tx (cervical cancer tx - radioisotope removed and replaced)
• interstitial tx (needles / pellets)

Question 16

How is a radioisotope used in treatment?

Answer 16

System of administration of a radioactive isotope that then concentrates in the body (I for thyroid cancer, Sr for bone metasteses)
Inpatient treatment until radioactivity to safe levels (half life).

Question 17

When is chemotherapy used? How does its effectiveness vary?

Answer 17

Not all tumours are sensitive to chemo
Highly sensitive tumours include acute leukaemias, some lymphomas, neuroblastoma
Modest senstivity, play a part in breast cancer, colorectal, ovarian cancer
Low sensitivity means chemo is of limited value for example in prostate cancer, primary brain tumours or in pallation of advanced disease

Question 18

How does treatment intent vary?

Answer 18

Radical (curative) e.g. chemo for testicular cancer

Neoadjuvant used prior to surgery

Adjuvant used after surgery

Palliative for symptom relief

Clinical trials (not normally blinded because unethical, normally an established regimen that is tweaked.)

Question 19

What routes of administration can be used for chemotherapy?

Answer 19

Oral
IV
Intra arterial 
IM
SC
Intracavity 
Topical
Intrathecal 
Wafer

Question 20

+s and -s of oral ROA

Answer 20

Convenient, outpatient (managed via telephone clinic, fewer GP appts)
Regimen can be very complicated
Only patient should handle tablets - cytotoxic (blister packs)
- variable absorption, easy to accidentally overdose

Question 21

+s and -s of IV ROA

Answer 21

IV bolus or infusion can be given
Initiated in hospital or can be out patient too
Peripheral cannula (central veins own access)
Central Venous Access Device (CVAD)
-implantable reservoir, external pump, elastomeric device (balloon and bottle)
Hickman Line

Question 22

What is intra-arterial ROA

Answer 22

artery feeding the organ is catheterised i.e. liver

Question 23

+s and -s of IM ROA

Answer 23

absorbed slowly so longer acting

Question 24

Examples of intracavity ROA

Answer 24

Intraperitoneal for ovarian cancer
Intrapleural for mesothelioma
Intravesical for bladder cancer

Question 25

When can topical chemotherapy be used?

Answer 25

For some skin cancers it is used, melanomas

Question 26

When is intrathecal ROA used? +s and -s of IT

Answer 26

Used in patients with a risk of CNS relapse
Strict guidelines re screening, prescribing, manufacture, checking delivery and administration
Patient safety lecture (never-ever events)

Question 27

What is a wafer ROA?

Answer 27

Carmustine wafer licensed for treatment of high grade glioma and recurrent glioma mutliformate
Cochrane review
During surgery, excise the tumour and up to 8 wafers can be placed in the cavity.

Question 28

Cycles of chemo

Answer 28

Usually given every 21 days
WCC nadir 10 days post chemo
Need WCC and ANC to recover before the next cycle
(ANC is absolute neutrophil count)