Cancer - Dr. Lasam PDF

There is an increasing trend and an expected rise in the cases of cancer, this is even underreported and the deaths, 113,369. What are the primary cancers that you sh...

There is an increasing trend and an expected rise in the cases of cancer, this is even underreported and the deaths, 113,369. What are the primary cancers that you should be acquainted with? Incidence, for both sexes BREAST, LUNG, COLORECTAL. We’ll give emphasis in colorectal, because in recent years, this is one of the more common causes of mortality, it ranks NEOPLASTIC DISORDERS 3rd next to the liver and almost always lung. APPROACH TO THE PATIENT WITH CANCER Most often than not you’ll be able to come up with lung cancer patients, worst case scenario, liver and colorectal cases DIAGNOSIS OF CANCER Most traumatic and revolutionary events that have ever happened. The prognosis of a person who has just been found to have pancreatic cancer is the same as the prognosis of the person with aortic stenosis who develops the first symptoms of congestive heart failure (median survival, ∼8 months). Cancer is an exception to the coordinated interaction among cells and organs. The most significant risk factor for cancer overall is age. two- thirds of all cases were in those aged >65 years The diagnosis of cancer may be the most traumatic and revolutionary event that has ever happened to a patient, to a family. Why revolutionary? Because it will change the dynamics of the family. The prognosis, as a generalist, you have to make sure that once you have encountered a patient with a metastatic disease, meaning it's outside the primary. (For ex. a breast primary going to the lungs, a breast primary going to the cranium or a breast going to the liver, don’t use the fear para bentahan ang pasyente. ) Most often than not, this is historical, when you meet a patient with metastatic disease, you will say, ah you’re going to refer 3-6 months. But they don't realize that there are The Philippine Cancer or Oncology may not necessarily be for other diseases which may be more life threatening because everybody. The thing is, in medical oncology, we do not only of the stigma attached to cancer. So kapag binigyan mo siya give a diagnosis that is not associated with life and death. ng diagnosis ng cancer ang unang tatanungin sayo “kelan po It entails a lot of effort from the doctor, from the patient and ako mamamatay doc” that is usually the case and that is the relatives. Sooner or later you will have your own patients, actually different from when you diagnose a patient with you will have to take care of cancer patients. You may know 1 hypertension, diabetes, even patients on dialysis. They won’t or 2 patients with cancer and you would know how difficult even dare ask you because they are scared, but for cancer their situation is. patients, they are scared but they want to know, so they’ll And that's where we get our separation from. When you come prepared become the expert in taking care of the disease, that is not Cancer is an exception to the coordinated interaction usually the one of the cases you see in the clinics. among cells and organs. In the normal scheme of things, Other doctors would find it very difficult to take care of cancer is secondary to any anomaly genetically engineered to cancer patients because they might remember some destroy the coordinated interaction among cells because unfortunate or unpleasant experience in the past. there wouldn’t be cancer if it's something that is attuned to Situation here in the Philippines. GLOBOCAN means global something that is not normal. I’d like you to understand that cancer observatory. We have noticed 188,976 new cases. cancer is a genetic disease. Genetic meaning, not only hereditary but it is in the genes, ang problema is nasa 🥷1 genes. Ano ba ang central dogma natin for cell cycle, DNA to subtypes under that. The grade has something to do with the RNA, transcription, etc. in any of those processes wherein natural aggressiveness of the histologic subtype. Invasiveness there is a derangement, aberrant expression of something that would upstage the patient and hence, a different therapy else predisposed by age, environmental factors, everything versus to that of with no skin involvement. boils down to a genetic change. There has to be that certain Molecular information, the new kid in the block, this is what change in the genetics but not necessarily hereditary. We’ll go makes us, the medical oncologists, because we're more fond through that. of looking into targets, when you molecularly classify your patients, then you get targets, and once you have targets, it's RISK OF DEVELOPING CANCER easier to treat. Gone are those days when we only offer Men- 40.5% chemotherapy. Women- 38.9% Chemotherapy is not targeted treatment, you do not need What is the most common risk factor that is associated with molecular information to give patients chemotherapy. But cancer? It’s always AGE, because habang tumatanda ka mas because there is advancement, and ever dynamic field of mataas yung chance mong magkaroon ng cancer. Because oncology, we bring chemo to a certain part of management you’re exposed to, the biases already for telling that age is a that is not considered an upfront treatment. Now we move on prognostic factor but in 2015-2016 there is a rise of cancer to targeted treatment and the latest is immunotherapy. among the young population 50% reduction in the sum of the products of the perpendicular diameters of all measurable lesions. 30% decrease in the sums of the longest diameters of lesions (Response Evaluation Criteria in Solid Tumors [RECIST]). Progressive disease appearance of any new lesion an increase of >25% in the sum of the products of the perpendicular diameters of all measurable lesions increase of 20% in the sums of the longest diameters by RECIST). Stable disease Tumor shrinkage or growth that does not meet any of these criteria Tumor markers May be useful in patient management in certain tumors. Response to therapy may be difficult to gauge with certainty. 🥷4  rising and falling levels of the marker are usually The incidence of depression in cancer patients is ∼25% associated with increasing or decreasing tumor burden, overall and may be greater in patients with greater respectively debility. This diagnosis is likely in a patient with a depressed mood (dysphoria) and/or a loss of interest in pleasure (anhedonia) for at least 2 weeks. It is not uncommon when a patient is diagnosed with CA they definitely go into depression, they definitely have question, “Why me?” lahat na ginawa ko, Bakit ako?” Medical therapy serotonin reuptake inhibitor ○ fluoxetine (10–20 mg/d) ○ sertraline (50– 150 mg/d) ○ paroxetine (10–20 mg/d) tricyclic antidepressant ○ amitriptyline (50–100 mg/d) ○ desipramine (75–150 mg/d) So, here is the list of medications that are usually prescribed to patients with CA and Depression. LONG-TERM FOLLOW-UP/ LATE COMPLICATIONS The optimal guidelines for follow-up care are not known. routine practice has been to follow the patient ○ monthly for 6–12 months, then, ○ every other month for a year, ○ every 3 months for a year, ○ every 4 months for a year, ○ every 6 months for a year, and then ○ annually. Follow-up would definitely be one of the cornerstones of therapy because we like to see them respond to treatment especially if tapos na sila magchemo. Generally, after 3 months of Alpha-fetoprotein can also be used in again seminoma, completing the treatment, magfollow up ka because you have non-seminomatous germ cell tumor but we also use it in to identify beginning early signs of recurrence. primary liver CA. ☆CEA has prognostic implication, not diagnostic. We do SUPPORTIVE CARE not use CEA to diagnose colon CA or rectal CA but we use it Supportive care, if there is one thing associated to CA, it’s to follow up patients preoperatively and we measure it always PAIN. They get to have a lot of pain medications, one post-operatively and check if CEA goes down and its after the other, to the point na kailangan na syang loadan by IV, prognostic treatment outcome. yung nakadrip, then down stage it to a patch then to morphine to end PSA lalo na lalaki pupunta sa clinic masakit ang bato, the WHO pain scale. But at the end of the treatment, if they’re pinaX-RAY biglang mayroong bone metastasis, kinain na ng already in palliative care you use morphine differently, it is that bukol. Walang lower urinary tract symptoms, SUSPECT will assist them into a smooth passing. PROSTATE CA, order PSA. Tumor markers - they are not stand-alone diagnosis but they help prognosticate CA. Pain Cancer and Depression variable frequency in the cancer patient: 25– 50% of patients present with pain at diagnosis The recognition and treatment→important 33% have pain associated with treatment components of management. 75% have pain with progressive disease Nausea 🥷5  Emesis in the cancer patient is usually caused by create a pericardial window in order to relieve both pleural and chemotherapy pericardial effusion. Its severity can be predicted from the drugs used Malignant ascites are usually treated with repeated to treat the cancer. paracentesis of small volumes of fluid. Nausea is secondary to the nature of the chemotherapy Malignant ascites for paracentesis but make sure you have albumin infusion especially if there is a large volume. ☆We expect acute emesis within 24 hours of treatment and paracentesis (5L) anything after 24 hours is considered delayed emesis. Nutrition Forms of emesis Cancer and its treatment may lead to a decrease in Acute emesis, the most common variety, occurs nutrient intake of sufficient magnitude. within 24 h of treatment. Advanced cancer experiences weight loss and Delayed emesis occurs 1–7 days after treatment; it decreased appetite. is rare, but, when present, usually follows cisplatin It remains controversial how to assess nutritional administration. status and when and how to intervene. Anticipatory emesis occurs before administration Nutrition is important because this time they dont have the of chemotherapy and represents a conditioned appetite because historically tumors produce a lot of hormones response to visual and olfactory stimuli previously that depresses the appetite. associated with chemotherapy delivery. Threshold for nutritional intervention Effusions 98% 5. BRAF inhibitor monotherapy topical 5-fluorouracil 6. Chronic ulcerations photodynamic therapy (PDT) topical immunomodulators, such as imiquimod. Systemic therapy with an SMO inhibitor, vismodegib or sonidegib, is indicated for patients with metastatic or advanced BCC that has recurred after local therapy and who are not candidates for surgery or RT. For treatment, we can have all these surgical local therapies. Basal cell has a high curative for local therapy, so you can BCC is ☆slowly enlarging but locally invasive, its metastatic have several local therapies but if it's found to have a metastatic potential is low compared to that of squamous. Because disease then you can have our SMO inhibitor squamous tends to metastasize in distant sites. These are the clinical features that could differentiate one of that basal from TREATMENT: Squamous Cell Carcinoma squamous. Surgical management with same with BCC ☆Cemiplimab, a monoclonal antibody targeting PD-1, which causes tumor regression in 47% of patients with advanced disease. squamous treatment is the same as that of SCC but again we've mentioned immunotherapy in melanoma, we didn't mention immunotherapy in basal cells, but in the squamous cell meron ring the one that changed the landscape. Before, we used to give cisplatin and carboplatin treatment based protocol for cutaneous SCC, now we've completely passed that era, now we are giving cimiplimab☆ for cutaneous SCC. Make sure that you are very much aware that your first role 🥷14 when you see a suspicious nodule is to differentiate it melanoma and non-melanoma. Cancers of the upper gastrointestinal tract include malignancies of the esophagus, stomach, and small bowel. upper GI, usually present symptomatically at the outset, but they usually have a long history of symptomatology. Kapag pumunta sayo ang upper GI lagi mong itatanong kelan ba CLINICAL FEATURES yan? Sometimes general physician failed to detect and identify warning symptoms “wala yan, dyspepsia lang yan” The most common symptoms leading to suspicion please refrain, mas magandang defensive ka. of esophageal cancer are: dysphagia or odynophagia and, less frequently, When we speak of upper GI, automatic, esophagus, from hematemesis or melena. (substantial obstruction esophageal area down to stomach and rarely, small of the esophageal lumen has occurred ) → locally intestine, wala pa akong small intestine na patient. It's always advanced if not metastatic disease. the esophageal and stomach. anorexia and weight loss fatigue and shortness of breath if anemia from gastrointestinal bleeding is present. I. ESOPHAGEAL CANCER Doc: male px presents with anemia - investigate further. Don’t give ferrous sulfate agad-agad. for esophageal, again this is one of the many many cancer na talagang symptomatic, “doc dati 1 week ago, kayang kaya ko pang lumunok ng pork, ngayon water nalang tapos masakit tapos nagagamit ko na dati yung shorts ko tapos bigla akong nahihilo, ano doc yung gagawin mo sakin?” Okay, nasabi ko na lahat ng warning symptoms ng esophageal CA, the patient clearly presents to you with obstructive symptoms. Doc nasaan yung obstructive doon? Yung change palang ng capacity to take in, if the patient further tells you na bawat intake niya sinusuka niya na, complete obstruction na yung diagnosis mo na yon. For esophageal, its a little different. Because for esophageal you're dealing with 2 histology, you can have squamous, you can have adenocarcinoma Id like you to appreciate that when a male patient comes to you with anemia, hindi mo bibgyan ng ferrous sulfate, you should investigate, a good clinician will not write a good prescription. Lalake? Male patient? Able? Tapos biglang anemic? Again the warning is, male patient walang karapatang mag anemia yan dahil we are not losing blood. Pag meron kayong makitang male patient, investigate. You don't give them iron supplements , how do they present? Upper obstruction, its always obstruction “ doc bakit habang kumakain para akong inaatake sa puso? Bakit kaya ganun?kaya ayaw ko na kumain kaya tignan mo nangayayat na ako.”Ang hirap itawid ng esophageal and 🥷15  gastric. here in the philippines we don't have screening advance, when we speak of locally advance at the very least unfortunately, for gastric meron ang japan at korea kasi its stage 3. So kapag nagkaroon ng symptoms, we dont expect matataas doon.only in asia sila lang ang meron because most it to be stage 1 or 2. often than not, walang effective na early detection kaya minsan sinasabi ko sa pasyente, kung magkakaroon ka, Survival no but control of symptom is yes magkakaroon ka. You need not blame someone, something bakit ka nagkaroon ng cancer. Ang laging presentation ng What makes the treatment different is the sequencing. For gastric at esophageal ay pagbabara laging nagsusuka ng squamous we do not usually subject them to surgery they recently ingested food, lagi yan, depende lang sa transit, can be treated with chemoradiation definitive upfront mas mababa mass matagal, mas proximal kahit pagkakain setting. Then we give chemotherapy after, but for isusuka na. adenocarcinoma we usually give upfront systemic therapy before surgery, what you need to know as a generalist is the clinical manifestation, eto dapat ang puspusan niyong Prognosis and screening inaaaral. How does a patient with esophageal CA presents The prognosis for patients with esophageal cancer to you, dysphagia and odynophagia, less frequently (all stages) is still poor. hematemesis or melena which can be the reason para a slow but steady improvement in 5-year survival magkaroon ng anemia and would present to you with fatigue has been noted. and shortness of breath. Because no effective early detection methods exist. II. TUMORS OF THE STOMACH Treatment The incidence of adenocarcinomas of the For patients without evidence of metastatic gastroesophageal junction has markedly increased disease, the goal of therapy is cure, usually by in the same areas over the past several decades. employing combined-modality therapies. The ingestion of high concentrations of nitrates Except for patients with early-stage esophageal found in dried, smoked, and salted foods may be a cancer ,which might be treated by surgery alone contributing factor. (or for very-early-stage lesions, by endomucosal Bacteria such as Helicobacter pylori and ingestion resection alone), systemic drug therapy plus of partially decayed bacterially contaminated food external-beam radiation therapy is a standard of may lead to the generation of carcinogenic nitrites care option for esophageal cancers. from nitrates For patients with squamous cell cancers of the H. pylori infection is a known driver in many cases upper and mid esophagus, combined of gastric cancer. BUT, gastric cancer occurs in only chemotherapy plus concurrent radiation therapy is a small subset of those infected. a standard of care option, with surgery reserved Supportive evidence that H. pylori infection is a for patients not achieving a complete radiographic causative factor in the development of gastric and endoscopic response. cancer includes prospective studies demonstrating For patients with metastatic disease, the goal of that treatment of H. pylori infection decreases the therapy is symptom palliation and life extension. overall risk of gastric cancer. inherited cancer susceptibility genes increase the For patient without evidence of metastatic disease, san ba risk of gastric cancer→ mutations of CDH1, which pupunta ang esophageal? Liver and lungs. Combined modality, encodes for the cell cohesion gene e-cadherin. i was mentioning earlier for squamous we give ○ germline ☆CDH1 mutations markedly chemoradiation, for adenocarcinoma we give systemic before increase the risk for the diffuse cell the surgery. and what we dont like about this is, kapag nakita (signet cell) gastric cancer subtype☆ mo ang gastric kapag nag present sila ng symptoms or ○ considered for prophylactic gastrectomy. esophageal it is usually locally advanced na, because we dont ○ ☆increase the risk for lobular breast have screening, we dont have early detection for cancer esophageal, when they present to you they are almost always locally advanced or metastatic and there's only this much that you can do, that's why most often than not they may not be eligible for upfront surgery, when you are given the option of surgery magpasalamat ka because its early, but if they offer you treatment options before the definitve therapy that only goes to show that your stage is locally 🥷16  for the stomach , actually the same but its presentation is quite primary gastric lymphomas different they do not usually present with obstructive gastrointestinal stromal tumors (GISTs) symptoms but present with vague abdominal discomfort with Upper endoscopy may reveal an ulcer or ulcerated other symptoms such as previous omeprazole, PPI, pabalik mass, biopsy of which shows adenocarcinoma. For balik, laging may dyspepsia. Naninilaw na yung mata, tapos the diffuse subtype of gastric cancer, a mass or nangangayayat, that's not dyspepsia na. ulceration may not be seen, but rather, thickened gastric rugae may be noted. Initial biopsy may not one of the many important association when GI or gastric reveal diffuse gastric cancer, which may track malignancy is predisease of h pylori. Okay ito itatanong ko na below the mucosal surface. naman sa inyo. Ano ang cause ng peptic ulcer disease? H pylori. Treatment POTENTIALLY CURABLE GASTRIC CANCER: what they saw in the clinical trials was one when they treated SURGERY the h pylori patient there is an decrease risk of gastric, dun Surgical removal of the primary tumor with nila. Nakuha, so aside from h pylori were always making sure negative microscopic margins (an R0 resection) that there is genetic mutation involve in gastric is a mutation in and with resection of regional lymph nodes is the CDH1☆ currently the only curative therapy; with surgery alone, 5-year survival rates are approximately 25%. ++++++++++++++++++++++++++++++++++++++++++++++++++ If tumor cells are found at the margin of resection CDH1 cohesive, encodes for the cell cohesion gene e (R1) or if visible cancer is left at the time of surgical cadherin, ibig sabihin if thats mutated nawala na yung removal of the primary tumor (R2), surgery is function, okay so that's the birth of chances of getting gastric palliative rather than curative. CA is increase at the same time there is a certain substance NEOADJUVANT AND POSTOPERATIVE ADJUVANT of gastric cancer associated with the CDH1 mutation and THERAPY FOR RESECTABLE GASTRIC CANCER that is a diffused☆. Docc bakit ganun? Kasi stomach cancer PALLIATIVE THERAPY FOR INCURABLE GASTRIC may present as nodular and diffuse, yung nakikita mo on CANCER. endoscopy pwede kang may nakitang lesion or pwedeng wala, Doc: even with resection, in 2 yrs time it may recur kapag wala ang the whole stomach lining is affected, that is the diffuse type. Potential curable gastric CA which is always impossible , because at that time you saw gastric there is always nodal linitis plastica - diffuse type of gastric CA, hindi ka makakakita involvement. Even if for a gastric patient, even if you ng ulcer but the whole lining is involve, kaya tignan mo ang underwent definitive curative intensive surgery in 2 years treatment for a diffuse, prophylactic gastrectomy, wala time magrere occur siya, unfortunately that's the natural tatanggalan kaa ng tyan kapag meron kang CDH1 mutation and behavior of gastric, that is why most of our patient would be what we don't like is you are also at risk for developing breast subjected to chemotherapy first, now were using CA that is considered to be lobular not ductal☆. chemotherapy and targeted therapy and another like melanoma, like esophageal we used immunotherapy. Clinical Features melena hematemesis pwedeng pwede magpresent hindi laging vague upper abdominal discomfort, hematemesis PUD, especially kapa yung chronicity, this cancers do not or melena, anorexia and early satiety, and develop overnight. unexplained weight loss. For patients with esophagogastric junction cancers, dysphagia or odynophagia may be the presenting symptom. Anemia may be found due to occult bleeding. ☆Physical Exam: left supraclavicular adenopathy (Virchow’s node) periumbilical mass (Sister Mary Joseph nodule) a pelvic mass on rectal exam (Blumer’s shelf) incidence rate for colorectal cancer in men and Ascites women