Approach To Patient With Cancer PDF

APPROACH TO PATIENT WITH CANCER Cancer Registry and Incidence Data 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: 13 sites, covering ~10% of U.S. population. Cancer Sta...

APPROACH TO PATIENT WITH CANCER Cancer Registry and Incidence Data 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: 13 sites, covering ~10% of U.S. population. Cancer Statistics (2017) 1.688 million new invasive cancer cases (836,150 men, 852,630 women). 600,920 cancer deaths (318,420 men, 282,500 women). Distribution by site and gender detailed in Table 65-1. Decline in cancer incidence by ~2% yearly since 1992. 1 in 4 deaths in the U.S. due to cancer. Risk Factors: Age and Gender Age as the main risk factor; most cases in those >65 years. 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 decreasing since 1990-1991. 21% decrease in cancer deaths among men, 12.3% among women from 1990 to 2010. 5-year survival: 39% (1960-1963) to 69% (2003-2009) for white patients. Lower survival rates in black patients, but gap narrowing. Incidence and mortality vary by race and ethnicity (Table 65-3). Global Cancer Statistics (2008) 12.7 million new cancer cases, 7.6 million deaths worldwide (GLOBOCAN 2008). Distribution by region: 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: Most common and deadliest worldwide. Incidence variability: 2/100,000 in African women, 61/100,000 in North American men. Breast cancer: Second most common, fifth in death causes. More common cancers in developed countries: Lung, breast, prostate, colorectal. More common cancers in less developed countries: Liver, cervical, esophageal. Stomach cancer: Similar incidence in developed and less developed countries, higher in Asia. Modifiable Risk Factors Nine factors contributing 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. PATIENT MANAGEMENT Routine History and Physical Examination Duration of symptoms: Indicates chronicity of the disease. Past medical history: Alerts to underlying diseases affecting treatment choices and side effects. Social history: Identifies occupational carcinogen exposure, smoking, alcohol consumption. Family history: Suggests familial cancer predisposition, need for surveillance or preventive therapy for siblings. DIAGNOSIS Cancer Diagnosis Relies primarily on invasive tissue biopsy. Tissue biopsy necessary for definitive cancer diagnosis. Noninvasive tests insufficient for cancer diagnosis. Fine-needle aspiration occasionally used (e.g., thyroid nodules). Biopsy enables evaluation of tumor histology, grade, invasiveness, and molecular diagnostics (e.g., cell-surface markers, intracellular proteins, molecular markers like t(8;14) translocation in Burkitt’s lymphoma). Genetic Links and Prognosis Certain gene expressions linked to prognosis and therapy response Multidisciplinary Management Post-Diagnosis Involves collaboration among primary care physicians, medical and surgical oncologists, radiation oncologists, oncology nurses, pharmacists, social workers, rehabilitation specialists, and others. Team works closely with patient and family. Patient Management Post- Cancer Diagnosis First priority: Determine the extent of disease (tumor burden). Curability inversely proportional to tumor burden. Early diagnosis (before symptoms or via screening) increases cure rates. Staging Process Involves both noninvasive and invasive diagnostic tests. Two types of staging: Clinical (physical exams, radiographs, scans) and Pathologic (surgical procedure findings). Pathologic staging includes histologic examination of tissues removed during surgery. Surgical procedures range from lymph node biopsy to thoracotomy, mediastinoscopy, or laparotomy. Tumor Spread and Staging Systems Tumor predilection for spreading to certain organs informs staging evaluation. Staging defines disease as localized, regional, or metastatic. TNM system (Tumor, Node, Metastasis) widely used for staging. Other systems: Dukes (colorectal cancer), FIGO (gynecologic cancers), Ann Arbor (Hodgkin’s disease). Patient Physiologic Reserve and Treatment Outcome Physiologic reserve significant in determining treatment response. Assessed via surrogate markers like Karnofsky or ECOG performance status. Poorer prognosis for older patients or those with lower performance status, unless tumor-related. Biologic Features of Tumor and Prognosis Oncogenes, drug-resistance genes, apoptosis-related genes, and metastasis genes influence therapy response and prognosis. Cytogenetic abnormalities, growth fractions (cell proliferation markers) impact behavior and aggressiveness of tumors. Tumor study increasingly influences treatment decisions. Tumor Heterogeneity and Treatment Responses Tumors with similar morphology may have different genetic abnormalities. Histologically different tumors can share genetic lesions predicting treatment response. Intra-tumor cell variation significant within a single patient. Treatment Determination Based on Disease Extent and Prognosis Treatment intent decided based on disease extent, prognosis, and patient's wishes: curative or palliative. Requires cooperation among medical professionals for planning. Treatment Strategies and Coordination Neoadjuvant therapy (chemo or chemo plus radiation before surgery) may improve outcomes in certain cancers like breast and head/neck cancers. Coordination crucial among medical oncologist, radiation oncologist, and surgeon, especially in combined-modality therapy. Chemotherapy and radiation may be sequential or concurrent. Surgical procedures might precede or follow other treatments. Adherence to standard or research protocols recommended; ad hoc modifications can compromise results. Access to Treatment Protocols Formerly influenced by local culture in university and practice settings. Now, standard treatment protocols and clinical studies accessible electronically across North America. Care for Non-Curative Patients Important role for physicians in caring for patients with palliative intent. Beyond medicines to alleviate symptoms, personal care and communication are vital. Resist pressure to reduce time with palliative care patients; value of personal interaction and support. Cancer Therapy Toxicity and Patient Management Addressing complications from both disease and treatment. Treatment-induced toxicity less acceptable in palliative therapy. Common side effects: nausea, vomiting, febrile neutropenia, myelosuppression. Tools available to minimize acute toxicity of treatment. Response to Treatment Assessment Physical examination and repeating imaging tests. Biopsy 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 disease: Tumor size changes not meeting response criteria. Unmeasurable sites or patterns (e.g., bone, lymphangitic lung) require biopsy for complete response verification. Tumor Markers Useful in assessing treatment response for certain tumors. Markers measured in serum or urine, indicating tumor burden changes. Specific markers listed in Table 65-6. Depression in Cancer Patients Incidence 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 maintain open, nonjudgmental communication. Awareness of possible unexpected toxicity from alternative treatments. Post-Treatment Assessment and Management Reassessment of previously involved tumor sites using radiography or imaging. Persistent abnormalities are biopsied. If disease persists, a new salvage treatment plan is developed by the multidisciplinary team. Follow-Up Care for Disease-Free Patients Regular follow-up for disease recurrence, but optimal guidelines are unclear. Traditional schedule: Monthly for 6-12 months, then decreasing frequency over years. Earlier focus on extensive laboratory and imaging tests at each visit. Recent studies (breast, melanoma, lung, colon cancer, lymphoma) show asymptomatic relapses not more curable than symptomatic ones. Emerging guidelines suggest less frequent follow-ups, focusing on history and physical examination. Recurrence Likelihood and Survival Likelihood of primary cancer recurrence decreases over time. 5-year survival without recurrence often considered a cure. Long-Term Medical Problems Can arise from the disease or its treatment. Awareness of these issues aids in detection and management. Detailed discussion in Chapter 91. Life After Cancer Most cured patients return to normal lives. SUPPORTIVE CARE PAIN 25-50% experience pain at diagnosis. 33% have pain related to treatment. 75% suffer pain with progressive disease. Approximately 70% due to tumor invasion (bone, nerves, blood vessels, mucous membranes) or obstruction. About 20% from treatment-related issues (surgical procedures, radiation, chemotherapy). 10% of pain cases unrelated to cancer or its treatment. Pain Management Tools Pharmacologic intervention effective in about 85% of patients. Other modalities for 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. Activation of vomiting center in medulla. Involves dopamine, serotonin, histamine, opioid, 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 agents. Mild/moderate emetogenic agents: Prochlorperazine (oral or rectal) 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 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 need local treatment for patients with a life expectancy of at least 6 months. Pleural Effusions Common in lung, breast cancer, and lymphomas. Exudative nature determined by effusion/serum protein or lactate dehydrogenase ratios. Initial treatment: Thoracentesis for symptomatic relief (typically short-term). If symptoms recur within 2 weeks, chest tube drainage and chemical sclerosis with bleomycin or doxycycline are used. Talc may be used if doxycycline and bleomycin are ineffective. Pericardial Effusions Treatment: Pericardial window creation, pericardial stripping. If surgery is not viable, sclerosis with doxycycline and/or bleomycin can be attempted. Malignant Ascites Treated with repeated small-volume paracentesis. If unresponsive to systemic therapy, peritoneovenous shunts may be inserted. Major complications: Occlusion, leakage, fluid overload. In severe liver disease, risk of disseminated intravascular coagulation. NUTRITION Decreased nutrient intake can lead to weight loss and metabolic alterations. Prevalence varies due to different definitions of cancer cachexia. Advanced cancer patients commonly experience weight loss and appetite decrease. Assessing Nutritional Status and Intervention Controversy over assessment methods and intervention timing. Objective assessments: Prognostic nutritional index including albumin levels, skinfold thickness, transferrin levels, hypersensitivity skin tests. Simpler approach: Intervene if unexplained weight loss >10%, serum transferrin