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Clinical Oncology

  • The practical application of knowledge and understanding about cancer and its treatment in order to optimise health outcomes for patient and family.
  • Remember patients are not islands, important to treat patient and not just the cancer itself. Also have to deal with family etc.
  • Disease vs illness
    • Disease = the entity that the patient has been diagnosed with
    • Illness = how the patient copes with the diagnosis
    • Can't just treat disease, must also treat illness

Steps in Cancer Management

Breaking bad news to patients, dealing with awkward situations is now very examinable. It is better to confront a situation and succeed.

  • Doesn't matter if you know the facts or not - you need a template to handle bad news that works for all diseases


  • Establish a diagnosis of cancer examination
    • History
    • Examination
    • confirm pathology
  • Do appropriate staging investigations
  • Establish treatment aim and action plan
  • Follow-up and aftercare

How would you manage a patient with x, y, z cancer?

ROTE LEARN THIS

  1. I would establish a diagnosis by taking a clinical history, performing a full physical examination and confirming/obtaining appropriate histopathology.
    • You need to study the oncology history, and you also need to study the general physical exam (back of Talley)
    • Know the presentations of common malignancies (breast cancer, prostate cancer, lump in neck)
  2. I would perform staging investigations appropriate to the particular malignancy. Staging investigations may include plain x-rays, abdominopelvic and chest CT scans, serum tumour markers, MRI, PET, bone scans.
  3. I would formulate a treatment plan following discussion of the patient’s case in a multidisciplinary team setting. Treatment may involve observation only, surgical resection, radiotherapy, systemic therapy or supportive treatment alone. My treatment decision would depend on both patient-related and cancerrelated factors. I would not treat the patient unless I had informed consent.
  4. Finally, I would offer follow-up appointments and aftercare.

Establishing Diagnosis

Cancer Signs and symptoms.PNG

Case 1

Lumpand bump.PNG

  • elderly Caucasian male
  • soft tissue mass in right preauricular area
  • hard/soft on palpation, transilluminescent, attached to underlying fascia, attached to overlying skin, texture
  • Ask patient to smile (facial nerve palsy), examine external auditory meatus, examine intraorally, examine neck for lymph nodes.
    • Think laterally to get HD - include everything about the lump and everything around the lump.
    • Probably parotid SCC
  • Consider pathology of clinical signs – aids in Hx taking and correlating clinical investigations
  • Not only describe lesion, but describe functional effects of the lesion (7th nerve palsy etc)
  • Let patient talk, don’t override them all the time. Good to build report. Gets a good understanding of illness

Histopathology of Cancer

  • Carcinoma
    • squamous cell
    • large cell
    • small cell
    • adenocarcinoma
  • Sarcoma
  • Lymphoma
  • Melanoma
  • Myeloma

Conditions that simulate malignancy

  • Don’t treat person for cancer if they don’t have cancer, you’ll get sued.. Ensure your diagnosis is accurate, and exclude other diagnoses.

Differentials:

  • Liver Metastases: macronodular cirrhosis, adenomas, abscesses, cystic disease, haemangiomas, haematomas.
  • Bone Metastases: osteomalacia, multiple trauma, osteoporotic crush fracture, aneurysmal bone cyst, fibrous dysplasia, hyper PTH (brown tumours), avascular necrosis, Paget’s disease, bone islands, haemangiomas

Staging Investigations

Localmetspread.PNG

  • Important to establish local extent of disease, just as much as metastatic disease
    • Eg. prostate cancer --> spread to bladder --> hydronephrosis --> renal failure
  • GBMs do not spread, so it's inappropriate to do a bone scan for a GBM.

Staging of Cancer

  • T. The extent of the primary tumour
  • N. The absence or presence and extent of regional
  • lymph node metastasis
  • M. The absence or presence of distant metastasis.
  • The addition of numbers to these three components

indicates the extent of the malignant disease

  • TNM rules:
    • All cases should be confirmed microscopically
    • Two classifications for each site – a) clinical based on physical examination, imaging etc b) pathological post biopsy
    • Assign the T (umour), N (nodes) and M (etastases) classification and then convert to stage
    • If in doubt assign to the lower T, N or M
    • Multiple synchronoustumours – use the highest stage for treatment decisions

Learn NNM staging for breast, prostate and lung cancer. T1 is earliest, T4 is involvement of adjacent organ.

  • Neck lump - describe the lump.
    • Supraclavicular fossa, near axilla (look at brachial plexus, axillary vessels, lymphatics). Then you'd examine their upper limb (neurological changes, swelling due to lymphatic spread). Only 50% for describing the lump.

Methods of Staging

  • Clinical
    • Physical Signs
    • Plain Xray
    • CT Scan
    • MRI Scan
    • Bone Scan
    • Blood Tests
      • General
      • Specific, including tumour markers
    • PET Scan
      • PET scans measure function not structure. Can still have normal structure on MRI and CT, but abnormal function. Therefore CT/MRI do not exclude malignancies
      • Important if you're going to offer a specific local treatment
  • Operative
    • Breast
    • Ovary
    • Lung

Brain tumour.PNG

  • Brain tumour
    • Secondary
      • Primary would be central and solitary
      • Secondary is multiple and peripheral
    • Other changes
      • Midline shift, white matter oedema
      • Shown also on CT, MRI
      • Treated with corticosteroids
    • One in temporal lobe.

Midline shift due to mass effect from oedema (global headache, lower GCS, focal signs due to anatomic location. Basically symptoms of raised ICP. Initial treatment = high dose corticosteroids) - NB: spinal cord compression, multiple cerebral metastases.

Establishing treatment aim and action plan

  • Curative
    • Definitive
    • Neoadjuvant
      • Prior to surgery
    • Adjuvant
      • Post-surgery to mop up microscopic remnants of malignancy
      • Eg. breast cancer, 25% have micro-metastatic disease, therefore adjuvant therapy is important
  • Palliation
    • Local control
    • Symptom relief

BCC treated with surgery or radiotherapy. Laryngeal carcinoma: laryngectomy or high dose chemotherapy.

Treatments can damage normal tissue as well. Need to weigh up what is scientifically recommended versus the patient's decision re: quality of life.

Treatment Decisions

  • Cancer Factors
    • Pathology/organ of origin
    • Stage
    • Natural History/tempo of disease
    • tumour grade
    • operable/inoperable
  • Patient factors
    • Age
    • General health
    • prior treatment for cancer
    • social support
    • preferences

NB: even though some cancers maybe curative, the patient's health status (Eg. elderly with comorbidities) may not be sufficient to withstand the cytotoxicity of curative therapy

Surgery may leave cancer cells around the site. Then the patient may need chemotherapy because of a high risk of local recurrence. Treat patient with adjuvants aimed to mop up disease that may remain there even after surgery, or in cases where the cancer tends to spread early (e.g. breast cancer).

  • Surgery most important treatment method for bulky disease
    • Must be removed with good margin
    • Adjuvant therapy is needed or else cancer can reoccur

Treatment permutations - different orderings of surgery, radiotherapy and chemotherapy.

  • Inflammatory breast cancer: 90% mortality: erosion of the nipple, peau d'orange. Not operable - needs chemotherapy up front.
  • Radiotherapy will cause an acute inflammatory reaction on the surface.
  • Can also cause a chronic reaction - later effects involve changes to growing tissues - this man has lost length of femur, SC tissue, hair etc. This is because he was a child when his tumour was cured.

Follow-up and Aftercare

  • Often allied health team required
  • Need interpersonal skills. Physician healer - talking to people relieves suffering. Incurable patients will not expect you to fix things - some problems aren't solvable.
  • Blah blah don't treat disease, treat patient.
  • Team in assignment - don't leave out the GP.