Clinical Aspects of Cancer Treatment

Question 1

What is the principle of cancer treatment?

Answer 1

Aim to kill cancer cells but spare normal cells

Question 2

Name the three chemotherapy settings

Answer 2

Adjuvant, metastatic, neoadjuvant

Question 3

Define the assessment of breast lumps

Answer 3

History and examination
Mammography
Ultrasound
MRI -> DCE-MRI
Distant staging
- Bone scan
- CT chest/abdomen/pelvis
- PET/CT

Question 4

Name the different stages in a primary tumour (T)

Answer 4

• Tis - carcinoma in situ
• T1 - tumour 2cm or smaller in greatest diameter
• T2 - tumour >2cm but not greater than 5cm
• T3 - tumour >5cm
• T4 - extension to skin or chest wall

Question 5

Define the different stages of regional lymph nodes

Answer 5

N0 - no regional lymph nodes metastasis
N1 - metastasis in 1-3 axillary lymph nodes
N2 - metastasis in 4-9 ancillary lymph nodes or radiologically involved internal mammary nodes
N3 - metastasis in 10 or more axillary nodes or ipsilateral infraclavicular lymph nodes

Question 6

Define the different stages of metatases

Answer 6

Mx - not evaluated
M0 - no distant metastases
M1 - distant metastases

Question 7

What should you look for on a pathology report?

Answer 7

• Tumour type - IDC/ILC/papillary/tubular etc
  
  • Associated DCIS/LCIS
  • Size
  • Grade (1-3) - how aggressive
  • Margins
  • Lymphovascular invasion
  • Nodes - extravascular speed, has it gone outside the capsule of the node, if its gone beyond the capsule you worry that there might be some cells in the axilla when the node has been removed.
  • ER/PgR/HER2 receptor status

Question 8

Name the two pathological types of tumours

Answer 8

Invasive ductal carcinoma
Invasive lobular carcinoma

Question 9

Name the three types of cell surface receptors in breast cancer

Answer 9

Oestrogen receptor (ER)
Progesterone receptor (PR)
HER2 receptor

Question 10

Define NACT with pembrolizumab

Answer 10

Use of neoadjuvant chemotherapy (NACT) in combination with pembrolizumab, an immune checkpoint inhibitor, before surgical treatment, especially in cancers like non-small cell lung cancer (NSCLC) and triple-negative breast cancer (TNBC).

Question 11

How is prostate cancer diagnosed?

Answer 11

Usually, with a raised PSA blood test
Digital rectal examination
MRI scan
Transrectal biopsy to prove whether or not it’s cancer

Question 12

What are the symptoms of prostate cancer?

Answer 12

Bladder frequency
Nocturia
Terminal dribbling/ poor stream

Question 13

What is the key prostate assessment criteria?

Answer 13

PSA Level (Prostate-Specific Antigen):

A blood marker used for screening and monitoring prostate cancer.

Higher levels may indicate more advanced or aggressive disease.

Number of Biopsy Cores Involved:

Indicates how many biopsy samples contain cancer.

A greater number suggests more extensive disease.

Percentage of Tissue Involved:

Refers to how much of each core is infiltrated with cancer.

Helps gauge tumor burden.

Extracapsular Extension / Seminal Vesicle Involvement:

Refers to cancer spreading outside the prostate capsule (Stage T3a) or into the seminal vesicles (T3b).

Indicates more advanced local disease.

Lymph Node Spread (on scans):

Metastasis to pelvic lymph nodes worsens prognosis and alters treatment strategy.

Question 14

What is the Gleason grade?

Answer 14

A histological grading system based on glandular patterns seen under the microscope.Two scores (1 to 5) are assigned:

Primary grade (most predominant pattern)

Secondary grade (second most predominant pattern)

These are added together (e.g., 3 + 4 = 7).

Minimum Gleason score for cancer is 6 (3 + 3), indicating well-differentiated, low-grade cancer.

Subjective assessment—depends on pathologist’s interpretation.

Question 15

What are the treatment options?

Answer 15

1) active surveillance - for LOW risk or slow-growing prostate cancer
2) Surgery
May be robotic, open or laparoscopic
3) Radiation therapy
4) Hormonal Therapy
5) Chemotherapy - usualy for metastatic, or castration-resistant prostate cancer
6) Targeted therapy and immunotherapy
7) Bone-directed therapy - used in metastatic disease with bone involvement

Question 16

Where is the most common spread of metastatic prostate cancer?

Answer 16

Bones

Question 17

Define gene expression tests

Answer 17

Analyse the activity of multiple genes (usually 21-70 genes) from tumour tissue to generate a recurrence risk score
Examples include:
- Oncotype DX
- MammaPrint
- Prosigna (PAM50)

Question 18

Define the risk of recurrence score (low/intermediate/high)

Answer 18

Helps assess likelihood of cancer returning.

A higher score suggests:

Greater chance of recurrence.

More potential benefit from adding chemotherapy to endocrine therapy.

Question 19

Define prognostic markers

Answer 19

Gives information about the overall cancer outcome e.g, recurrence risk), regardless of treatment

Question 20

Define predictive markers

Answer 20

Provides insight into the likely benefit of a specific therapy like chemotherapy

Question 21

Explain the three current chemotherapy regimens

Answer 21

➤ CMF:
Cyclophosphamide + Methotrexate + 5-Fluorouracil

One of the oldest regimens.

Still used in selected patients who cannot tolerate more aggressive regimens.

Less toxic but also less effective in high-risk cases.

➤ FEC:
5-Fluorouracil + Epirubicin + Cyclophosphamide

An anthracycline-based regimen.

Often used for ER-positive, node-positive, or high-risk early breast cancer.

➤ TAC / FEC-T:
TAC = Docetaxel + Doxorubicin (Adriamycin) + Cyclophosphamide

FEC-T = FEC followed by Docetaxel

Taxane-containing regimens offer improved outcomes in high-risk or node-positive breast cancer.

Commonly used when more intensive treatment is needed.