Podcast
Questions and Answers
What is the estimated lifetime cancer risk for men?
What is the estimated lifetime cancer risk for men?
Which cancer site has the highest incidence worldwide?
Which cancer site has the highest incidence worldwide?
Which modifiable risk factor is NOT mentioned as contributing to global cancers?
Which modifiable risk factor is NOT mentioned as contributing to global cancers?
What trend has been observed in cancer deaths among men from 1990 to 2010?
What trend has been observed in cancer deaths among men from 1990 to 2010?
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Which age group has the highest age-specific risk for developing cancer?
Which age group has the highest age-specific risk for developing cancer?
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How has the 5-year survival rate for white cancer patients changed from 1960-1963 to 2003-2009?
How has the 5-year survival rate for white cancer patients changed from 1960-1963 to 2003-2009?
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What percentage of new cancer cases globally occurred in Asia according to 2008 statistics?
What percentage of new cancer cases globally occurred in Asia according to 2008 statistics?
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What factor contributes to over one-third of global cancers?
What factor contributes to over one-third of global cancers?
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What is the primary method for definitive cancer diagnosis?
What is the primary method for definitive cancer diagnosis?
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Which of the following is NOT typically involved in multidisciplinary cancer management?
Which of the following is NOT typically involved in multidisciplinary cancer management?
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What is the significance of tumor burden in cancer treatment?
What is the significance of tumor burden in cancer treatment?
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Which staging system is commonly used for solid tumors?
Which staging system is commonly used for solid tumors?
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Which feature is NOT assessed by physiologic reserve markers?
Which feature is NOT assessed by physiologic reserve markers?
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What role do genetic expressions play in cancer management?
What role do genetic expressions play in cancer management?
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Which type of staging involves histological examination of surgically removed tissues?
Which type of staging involves histological examination of surgically removed tissues?
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Which type of cancer treatment component is commonly involved in post-diagnosis management?
Which type of cancer treatment component is commonly involved in post-diagnosis management?
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What is an essential step when dealing with sites that are unmeasurable?
What is an essential step when dealing with sites that are unmeasurable?
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Which symptoms are commonly associated with depression in cancer patients?
Which symptoms are commonly associated with depression in cancer patients?
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What is part of the traditional follow-up schedule for disease-free patients?
What is part of the traditional follow-up schedule for disease-free patients?
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What should physicians maintain when patients seek unproven treatments?
What should physicians maintain when patients seek unproven treatments?
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What percentage of cancer patients experience pain at diagnosis?
What percentage of cancer patients experience pain at diagnosis?
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What is the typical follow-up care focus for patients with a low likelihood of recurrence?
What is the typical follow-up care focus for patients with a low likelihood of recurrence?
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How do cytogenetic abnormalities affect tumor behavior?
How do cytogenetic abnormalities affect tumor behavior?
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What is the likelihood of primary cancer recurrence as time progresses?
What is the likelihood of primary cancer recurrence as time progresses?
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What is a critical factor when determining treatment intent for a patient?
What is a critical factor when determining treatment intent for a patient?
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What fraction of cancer patients report pain related to their treatment?
What fraction of cancer patients report pain related to their treatment?
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What is the purpose of neoadjuvant therapy?
What is the purpose of neoadjuvant therapy?
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Which type of care requires a vital personal interaction component?
Which type of care requires a vital personal interaction component?
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What describes progressive disease in response to treatment assessment?
What describes progressive disease in response to treatment assessment?
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How has access to treatment protocols changed in recent years?
How has access to treatment protocols changed in recent years?
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What is a common side effect of cancer therapy that is considered less acceptable in palliative treatment?
What is a common side effect of cancer therapy that is considered less acceptable in palliative treatment?
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What is the significance of intra-tumor cell variation?
What is the significance of intra-tumor cell variation?
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What percentage of patients find pharmacologic interventions effective for pain management?
What percentage of patients find pharmacologic interventions effective for pain management?
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Which type of emesis occurs within 24 hours of chemotherapy treatment?
Which type of emesis occurs within 24 hours of chemotherapy treatment?
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Which receptor antagonists are effective for managing acute emesis?
Which receptor antagonists are effective for managing acute emesis?
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What is typically the initial treatment for symptomatic pleural effusions?
What is typically the initial treatment for symptomatic pleural effusions?
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Which combination therapy is recommended for high emetogenic agents to prevent vomiting?
Which combination therapy is recommended for high emetogenic agents to prevent vomiting?
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Which of the following is NOT typically a treatment option for managing anticipatory emesis?
Which of the following is NOT typically a treatment option for managing anticipatory emesis?
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How should one manage delayed emesis after chemotherapy?
How should one manage delayed emesis after chemotherapy?
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What common characteristic do malignant pleural effusions share?
What common characteristic do malignant pleural effusions share?
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Study Notes
Cancer Registry and Incidence Data
- Lack of a nationwide cancer registry in the U.S.
- Incidence estimated from SEER database and U.S. Census data.
- SEER data covers ~10% of the U.S. population.
- In 2017, there were 1.688 million new invasive cancer cases (836,150 men, 852,630 women) and 600,920 cancer deaths (318,420 men, 282,500 women).
- Cancer incidence decreased by ~2% yearly since 1992.
- 1 in 4 deaths in the U.S. are due to cancer.
Risk Factors: Age and Gender
- Age is the primary risk factor, with most cancer cases occurring in individuals over 65 years old.
- Cancer incidence increases with age.
- Lifetime cancer risk: 44% for men, 38% for women.
- Age-specific risk: Increases from 1 in 29 men and 1 in 19 women (under 49 years) to 1 in 3 men and 1 in 4 women (over 70 years).
Trends and Survival Rates
- Cancer deaths have been decreasing since 1990-1991.
- From 1990 to 2010, there was a 21% decrease in cancer deaths among men and a 12.3% decrease among women.
- 5-year survival rates increased from 39% (1960-1963) to 69% (2003-2009) for white patients.
- Survival rates are lower in black patients, although the gap is narrowing.
- Incidence and mortality vary by race and ethnicity.
### Global Cancer Statistics
- In 2008, there were 12.7 million new cancer cases and 7.6 million cancer deaths globally.
- Regional distribution: 45% Asia, 26% Europe, 14.5% North America, 7.1% Central/South America, 6% Africa, 1% Australia/New Zealand.
Cancer Incidence by Type and Region
- Lung cancer is the most common and deadliest cancer worldwide.
- Incidence variability: 2/100,000 in African women, 61/100,000 in North American men.
- Breast cancer is the second most common cancer, fifth in cause of death.
- More common cancers in developed countries: Lung, breast, prostate, colorectal.
- More common cancers in less developed countries: Liver, cervical, esophageal.
- Stomach cancer has similar incidence in developed and less developed countries, with higher rates in Asia.
Modifiable Risk Factors
- Nine factors contribute to over one-third of global cancers:
- Smoking
- Alcohol
- Obesity
- Physical inactivity
- Low fruit/vegetable intake
- Unsafe sex
- Air pollution
- Indoor smoke from household fuels
- Contaminated injections
Routine History and Physical Examination
- Symptoms duration aids in determining disease chronicity.
- Past medical history identifies underlying diseases influencing treatment choices and potential side effects.
- Social history reveals occupational carcinogen exposure, smoking, and alcohol consumption habits.
- Family history suggests familial cancer predisposition, requiring surveillance or preventive therapies for relatives.
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Cancer Diagnosis
- Invasive tissue biopsy is the primary method of cancer diagnosis.
- Noninvasive tests are insufficient for cancer diagnosis.
- Biopsy allows for evaluation of tumor histology, grade, invasiveness, and molecular diagnostics.
- Fine-needle aspiration is occasionally used for diagnosis (e.g., thyroid nodules).
Genetic Links and Prognosis
- Specific gene expressions are linked to prognosis and response to therapy.
Multidisciplinary Management Post-Diagnosis
- Involves collaborative efforts from primary care physicians, medical and surgical oncologists, radiation oncologists, nurses, pharmacists, social workers, rehabilitation specialists, and other professionals.
- The team closely works with the patient and family.
Patient Management Post-Cancer Diagnosis
- The main initial priority is determining the extent of disease (tumor burden).
- Curability is inversely proportional to tumor burden.
- Early diagnosis (before symptoms or via screening) improves cure rates.
Staging Process
- Involves both noninvasive and invasive diagnostic tests.
- Two types of staging: Clinical (based on physical exams, radiographs, and scans) and Pathologic (based on findings from surgical procedures).
- Pathologic staging includes histological examination of tissues removed during surgery.
- Surgical procedures range from lymph node biopsy to thoracotomy, mediastinoscopy, or laparotomy.
Tumor Spread and Staging Systems
- Tumors have predilection for spreading to specific organs, informing staging evaluation.
- Staging categorizes disease as localized, regional, or metastatic.
- The TNM system (Tumor, Node, Metastasis) is widely used for staging.
- Other systems include Dukes (colorectal cancer), FIGO (gynecologic cancers), and Ann Arbor (Hodgkin's disease).
Patient Physiologic Reserve and Treatment Outcome
- Physiologic reserve significantly influences treatment response.
- Assessed via surrogate markers like Karnofsky or ECOG performance status.
- Patients with poorer physiologic reserve (older patients, lower performance status) generally have poorer prognoses, unless the condition is tumor-related.
Biologic Features of Tumor and Prognosis
- Oncogenes, drug-resistance genes, apoptosis-related genes, and metastasis genes impact therapy response and prognosis.
- Cytogenetic abnormalities and growth fractions (cell proliferation markers) influence tumor behavior and aggressiveness.
- Tumor study increasingly influences treatment decisions.
Tumor Heterogeneity and Treatment Responses
- Tumors with similar morphology can have different genetic abnormalities.
- Histologically different tumors can share genetic lesions predicting treatment response.
- Intra-tumor cell variation is significant within a single patient.
Treatment Determination Based on Disease Extent and Prognosis
- Treatment intent (curative or palliative) is decided based on disease extent, prognosis, and patient preferences.
- Requires cooperation among medical professionals for treatment planning.
Treatment Strategies and Coordination
- Neoadjuvant therapy (chemotherapy or chemotherapy plus radiation before surgery) can improve outcomes in specific cancers like breast and head/neck cancers.
- Coordination is crucial among medical oncologist, radiation oncologist, and surgeon, especially in combined-modality therapy.
- Chemotherapy and radiation can be sequential or concurrent.
- Surgical procedures can precede or follow other treatments.
- Adherence to standard or research protocols is recommended; ad hoc treatment modifications can compromise treatment success.
Access to Treatment Protocols
- Previously influenced by local culture in university and practice settings.
- Now, standard treatment protocols and clinical studies are electronically accessible across North America.
Care for Non-Curative Patients
- Physicians play a vital role in caring for patients with palliative intent.
- Beyond symptom alleviation with medications, personal care and communication are crucial.
- Resist pressure to reduce time spent with palliative care patients; value personal interaction and support.
Cancer therapy Toxicity and Patient Management
- Addresses complications arising from both the disease and treatment.
- Treatment-induced toxicity is less acceptable in palliative therapy.
- Common side effects include: nausea, vomiting, febrile neutropenia, and myelosuppression.
- Tools are available to minimize acute treatment toxicity.
Response to Treatment Assessment
- Involves physical examinations and repeated imaging tests.
- Biopsy is necessary for complete response documentation, not required for macroscopic residual disease.
- Response definitions:
- Complete: Disappearance of disease.
- Partial: Significant reduction in lesions.
- Progressive: New lesions or significant increase in existing ones.
- Stable: Tumor size changes not meeting response criteria.
- Unmeasurable sites or patterns require biopsy for complete response verification.
Tumor Markers
- Useful for assessing treatment response for specific tumors.
- Markers are measured in serum or urine, indicating changes in tumor burden.
- Specific markers are listed in table 65-6.
Depression in Cancer Patients
- Incidence is around 25%, higher in more debilitated patients.
- Symptoms: Dysphoria, anhedonia, appetite/sleep changes, psychomotor issues, fatigue, guilt, concentration problems, suicidal thoughts.
- Treatment: Medication (e.g., SSRIs, tricyclic antidepressants), psychotherapy, support groups, guided imagery.
- Maintain therapy for 6 months after symptom resolution.
Unconventional Treatment Approaches
- Patients may seek unproven treatments.
- Physicians should engage in open and non-judgmental communication.
- Awareness of possible unexpected toxicity from alternative treatments is essential.
Post-Treatment Assessment and Management
- Reassessment of previously affected tumor sites using radiography or imaging.
- Persistent abnormalities require biopsy.
- If disease persists, a new salvage treatment plan is developed by the multidisciplinary team.
Follow-Up Care for Disease-Free Patients
- Regular follow-up is necessary to monitor for disease recurrence, though optimal guidelines are unclear.
- Traditional follow-up schedule: Monthly for 6-12 months, then decreasing frequency over years.
- Earlier focus on extensive laboratory and imaging tests at each visit.
- Recent studies suggest less frequent follow-ups, focusing on history and physical examination.
- Asymptomatic relapses may not be more curable than symptomatic ones.
Recurrence Likelihood and Survival
- The likelihood of primary cancer recurrence decreases over time.
- 5-year survival without recurrence is often considered a cure.
Long-Term Medical Problems
- May arise from the disease or its treatment.
- Awareness of these issues aids in detection and management.
Life After Cancer
- Most cured patients return to normal lives.
PAIN
- 25-50% of patients experience pain at diagnosis.
- 33% have pain related to treatment.
- 75% suffer pain with progressive disease.
- Approximately 70% of pain is due to tumor invasion (bone, nerves, blood vessels, mucous membranes) or obstruction.
- About 20% of pain is due to treatment-related issues (surgical procedures, radiation, chemotherapy).
- 10% of pain cases are unrelated to cancer or its treatment.
Pain Management Tools
- Pharmacologic intervention is effective in about 85% of patients.
- Other modalities provide additional relief (~12%):
- Antitumor therapy (surgical relief, radiation therapy, strontium-89/samarium-153 for bone pain).
- Neurostimulatory techniques, regional analgesia, neuroablative procedures.
- Very few patients have inadequate pain relief with appropriate measures.
NAUSEA
- Commonly caused by chemotherapy.
- Severity depends on the chemotherapy drugs used.
- Three forms based on timing:
- Acute Emesis: Within 24 hours of treatment.
- Delayed Emesis: 1-7 days post-treatment, often after cisplatin.
- Anticipatory Emesis: Before chemotherapy, a conditioned response to associated stimuli.
Mechanism of Acute Emesis
- Stimuli in chemoreceptor trigger zone, cerebral cortex, and intestinal tract activate the vomiting center in the medulla.
- Involves dopamine, serotonin, histamine, opioid, and acetylcholine receptors.
- Serotonin receptor antagonists (e.g., ondansetron, granisetron) and neurokinin receptor antagonists (e.g., aprepitant, fosaprepitant) are effective.
Emesis Therapy Approach
- Tailor therapy to the emetogenic potential of chemotherapy agents.
- Mild/moderate emetogenic agents: Prochlorperazine (oral or rectal) is effective, enhanced by pre-chemotherapy administration. Dexamethasone can improve prochlorperazine's efficacy.
- High emetogenic agents: Combination therapy starting 6-24 hours before treatment. Example regimen: Ondansetron with dexamethasone, plus oral aprepitant for acute and delayed vomiting prevention.
Managing Delayed and Anticipatory Emesis
- Delayed emesis: Oral dexamethasone and metoclopramide (dopamine and serotonin receptor antagonist at high doses).
- Anticipatory emesis: Prevention in early therapy cycles; prophylactic antiemetics or behavior modification if needed.
EFFUSION
- May occur in the pleural cavity, pericardium, or peritoneum.
- Asymptomatic malignant effusions often don't require treatment.
- Symptomatic effusions in tumors responsive to systemic therapy usually respond to underlying tumor treatment.
- Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment for patients with a life expectancy of at least 6 months.
Pleural Effusions
- Common in lung, breast cancer, and lymphomas.
- Exudative nature is determined by effusion/serum protein or lactate dehydrogenase ratios.
- Initial treatment: Thoracentesis for symptomatic relief (typically short-term).
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Description
Test your knowledge on the statistics and trends related to cancer incidence and its risk factors. This quiz covers the U.S. cancer registry, incidence data from the SEER database, and the impact of age and gender on cancer risk. Dive into the trends from the past decades and the survival rates associated with cancer.
