Principles of cancer care and chemotherapy

Fundamental principles
• Primary of patient welfare
• Patient autonomy
• Social justice
Patient safety
• * medical errors and iatrogenic complication
Systemic anti-cancer treatment
• Cell cycle nonspecific agents
◦ Alkylating agent
‣ Cyclophosphamide
• DNA damage -> cell death
• Cause cross linkage
• S/E : neurptoxicity
◦ Platinol
‣ Cisplatin
• Act like DNA alkylating agents
• More potent
• Used for solid tumor
• S/E : GI disturbance,neuro and nephro toxicity
◦ Anthracyclines
‣ Doxorubicin
• Oxidised Fe+ -> free radical
• S/E : cardiotoxicity
◦ Topoisomerase II inhibitor and Topoisomerase I inhibitor
‣ Etoposide
‣ Topotecan
‣ Like anthracycline but not produce cardiotoxicity effect
• Cell cycle specific agents
◦ Antimetabolite ( S phase)
‣ MTX (folic)
• Purine analog
• S/E : mucositis ,contraindication in pregnancy
‣ 5-FU
• Pyrimidine analog
• Used with leucovorin
• S/E: BM suppression
‣ 6-MP
• Purine analog
◦ Antitumor antibiotic ( G2-M phases)
‣ Bleomycin
• S/E : pulmonary fibrosis
◦ Taxanes
‣ Paclitaxel
◦ Vinca alkaloid ( Mphase)
‣ Vinblastine
‣ Vincristine
• Inhibit beta tubular to form mitotic spindle
• EGFR : cetuximab
• HER2 : Transtuzumab
• VEGF : Bevacizumab
• CD20 : rituximab
• CD52 : Alemtuzumab ( all lymphocyte)

Analgesic ladder
• 1
◦ Aspirin
◦ Paracetamol
◦ NSAID
• 2
◦ Codeine
◦ Tramadol
• 3
◦ Morphine
◦ Oxycodone
◦ Fentanyl

Pain
• Neuropathic pain
◦ Antidepressant
◦ Anticonvulsant
• Bone pain
◦ bisphosphanate
◦ Steroids

Immunotherapy + chemotherapy : for non -targeting therapy

CTLA4/PD1 : T cell exhaust

• Adenocarcinoma : peripheral
• Airway in the center : squamous and small cell
• Lung : plastin
• Breast : doxorubicin
• Triple negative : BRCA
• Antimetabolite : not alopecia ]
Breast cancer
• Tamoxifen ( anti - estrogen) : lymph node - , estrogen receptor + , pre-post menopasusal
• Aromatase inhibitor : lymph node + ,estrogen + ,postmenopasusal
◦ Chemotherapy

• Lack of growth over 2 years + calcification in lung

◦ Benign
◦ Screening : low dose CT

• Screening HCC in HBV

◦ AFP + ultrasound 6 month
• EGFR TKI : adenocarcinoma of lung
Cancer
• Round large,acantholytic cell : Paget's disease
• mTor : endocrine system
• Anti metabolite :not causing alopecia
• Chemotherapy
◦ Kill CA cell ---> Ag release ---> recognise
• Immunotherapy to help T cell kill Ca
◦ CTLA-4 PD1
• Top 5 CA
◦ Lung
◦ Breast
◦ Colon
◦ Nasopharyngral carcinoma
◦ Liver
• Pancoast tumor :Horner's syndrome
• Screen cancer in lung :low dose CT
• Squamous : cavitation
• Milky Color , pleural effusion : Hodgkin lymphoma
• Weight loss ,bloody sputum , asymptomatic hand : pancoast
• Lymph node that metastasised from lung : paratrachial ,arotopulmonary ,supra carinal :
all cannot resectable
• Female gender good prognosis for lung CA
◦ EGFR mutation much -> targeted therapy -> good prognosis
• Bad prognosis : TP53 ; chromosome 17 p
• 8 driver mutation
◦ KRAS
◦ EGFR
◦ HER2
‣ Different treatment
‣ Need targeted therapy
• Early treatment of lung cancer
◦ Lobectomy : early treatment
◦ Advanced : chemoradiotherapy
◦ Systemic : plastin based
• Next generation sequencing for targeted therapy
• FISH and PCR : only certain type of gene
• Immuno therapy in case of not
• Benign : calcification
• EGFR: adenocarcinoma of lung in Asian 40 %
• Treatment of small cell lung cancer
◦ Limited
‣ Prophylaxis : crania radiation as small cell cancer likely to metastasis to brain
◦ Extensive
‣ Immuno +. Chemo
• Strongest of breast cancer : family history
• BRCA2 are most likely to be ovarian cancer
• Screening of breast cancer
◦ Mammogram ;> 50 years
• BRCA1 is likely to be breast cancer
• Estrogen - , + her2 : poor prognosis ; transtuzumab
• Sentinel node of breast cancer : axially node
◦ Early stage of breast cancer : lobectomy , chemotherapy and radiation if wanna
preserving
◦ Advance : neoadjuvant and chemotherapy ,if HER2 : transtizumab
‣ Chemo--- > cut --> chemo
◦ If hormone therapy and not respond --> chemotherapy
• HCC
 ◦ Prevent by vaccination ;HBV,HCV
◦ Ultrasound and AFP every 6 months
• HCC enhanced at arterial phase : high vascularity ; need onlyCT ;not need biopsy
• Cholangiocarcinoma
◦ Intrahepatic ( peripheral cholangiocarcinoma)
‣ HBV,HCV
◦ Hilar
‣ Most common
◦ Distal ( extra hepatic)
‣ O.viverini
• Neck mass, generalized lymphadenopathy ( suspect EBV ,nasopharyngeal carcinoma)
◦ PBS and bone marrow study
• NPC
◦ EBV
◦ Squamous is common
◦ Cranial nerve 6 , invaded base of skull
◦ epitaxis
◦ nasal stiffness
◦ Disseminated to bone and visceral organ
• Oropharyngeal carcinoma
◦ Smoking and HPV
• Cytokeratin : epithelial origin
◦ 7+20+ : ovarian ,urothehelium ,upper Gi : adenocarcinoma
◦ 7+ ,20- : breast lung bone diaphragme thyroid salivary gland
◦ 7- ,20 + : merkel diverticulum
◦ 7- ,20- : the rest