APPROACH TO THE PATIENT WITH CANCER

LECTURE BY: DR. FRANCIS NIÑO ARCINAS CAÑEDO, MD, FPCP (HARRISON’S INTERNAL MEDICINE CHAPTER 65)
3RD YEAR, 2ND SEMESTER- ONCOLOGY MODULE

INTRODUCTION -
● A patient with cancer is attacked and invaded by a
disease that could be anywhere in the body
● Cancer is an exception to the coordinated interaction
among cells and organs
● The cancer cell competes to survive using natural
mutability and natural selection to seek advantage over
normal cells in a recapitulation of evolution

THE MAGNITUDE OF THE PROBLEM -

● No nationwide cancer registry exists
● In 2017, 1.688 million new cases of invasive cancer were
diagnosed and 600,920 persons died from cancer
● Cancer incidence has been declining by 2% each year
since 1992
● Cancer is the cause of one in four deaths in the United
States
● Furthermore, 189 of every 100,000 Filipinos are afflicted
with cancer while four Filipinos die of cancer every hour or
96 cancer patients everyday, according to a study
conducted by the University of the Philippines’ Institute of
Human Genetics, National Institutes of Health
● Cancer is the second leading cause of death among
Filipinos. The most common cancers are breast, lung,
colorectal, liver, and prostate
● The most significant risk factor for cancer overall is AGE
○ ⅔ of all cases were in those aged >65 years
● Cancer incidence increases as the third, fourth, or fifth
power of age in different sites
○ I.e., for the interval between birth and age 49
years, 1 in 29 men and 1 in 19 women will
develop cancer
● Overall, men have a 44% risk of developing cancer at
some time during their lives; women have a 38% lifetime
risk

● Cancer is the second leading cause of death behind Heart

Disease
● Cancers are more often deadly in blacks
● The 5-year survival was 61% (2003-2009)

APPROACH TO THE PATIENT WITH CANCER 1

 CANCER AROUND THE WORLD - PHYSIOLOGIC RESERVE -
● Worldwide, 45% of new cases were in Asia (2008) ● A second major determinant of treatment outcome
● Lung cancer is the most common cancer and the most ● Is a determinant of how a patient is likely to cope with the
common cause of cancer death in the world physiologic stresses imposed by the cancer and its
● Breast cancer is the second most common cancer treatment
worldwide ● Difficult to assess directly→ “Surrogate Markers”
● Lung, breast, prostate and colorectal cancers are more
common in more developed countries
● Liver, cervical, and esophageal cancers are more
common in less developed countries
● There are 9 modifiable risk factors that are responsible
for >⅓ of cancers worldwide:
1. Smoking
2. Alcohol consumption
3. Obesity
4. Physical inactivity
5. Low fruit and vegetable consumption
6. Unsafe sex
7. Air Pollution
8. Indoor smoke from household fuels
9. Contaminated injections

PATIENT MANAGEMENT -
● History and Physical Examination is key
● The diagnosis of cancer relies most heavily on invasive
tissue biopsy and should never be made without obtaining
tissue
● NO NONINVASIVE DIAGNOSTIC TEST IS SUFFICIENT
TO DEFINE A DISEASE PROCESS AS CANCER
● TUMOR: Histology, Grade, Invasiveness, Cell-surface
markers, Intracellular proteins and molecular markers
● Occasionally, a patient will present with a metastatic
disease process that is defined as cancer on biopsy but
has no apparent primary site of disease
● Once the diagnosis of cancer is made, the management
of the patient is best undertaken as
MULTIDISCIPLINARY COLLABORATION
● The FIRST PRIORITY is ESTABLISHED DIAGNOSIS
then DETERMINE THE EXTENT OF DISEASE
● The curability of a tumor usually is inversely proportional
to the tumor burden
● IDEALLY, the tumor will be diagnosed before symptoms
develop or as a consequence of screening efforts
● Increasingly, the biologic features of the tumor are being
STAGING - related to prognosis (oncogenes, drug-resistance genes,
● The extent of disease is evaluated by a variety of etc.)
noninvasive and invasive diagnostic test and procedures ● Tumor with higher growth fractions behave more
● CLINICAL STAGING and PATHOLOGIC STAGING aggressively with lower growth fractions
● Surgical procedures performed may include a simple ● Host genes involved in drug metabolism can influence
lymph node biopsy or more extensive procedures such as safety and efficacy of particular treatments
thoracotomy, mediastinoscopy, or laparotomy ● ENORMOUS HETEROGENEITY HAS BEEN NOTED BY
● SURGICAL STAGING STUDYING TUMORS

TNM SYSTEM - MAKING A TREATMENT PLAN -

● Anatomically based system that categorizes the tumor on ● CURATIVE or PALLIATIVE?
the basis of: ● NEOADJUVANT THERAPY
○ The size of the primary tumor lesion (T1-4) ● Standard protocols and Clinical research protocols
○ The presence of nodal involvement (N0 and N1) ● The skilled physician also has much to offer the patient for
○ The presence of metastatic disease (M0 and M1) whom curative therapy is no longer an option
● Other anatomic staging system: DUKES, IFOG, ANN
ARBOR
● Certain tumors cannot be grouped on the basis of
anatomic considerations (LEUKEMIA, MYELOMA, and
LYMPHOMA)

APPROACH TO THE PATIENT WITH CANCER 2

MANAGEMENT OF DISEASE AND TREATMENT
COMPLICATIONS -
● Address the complications of both the disease, its
treatment, and the complex psychosocial problems
● In the short term during a course of curative therapy, the
patient’s functional status may decline
● Treatment-induced toxicity is less acceptable if the goal of
therapy is palliation
● The most common side effects of treatment are:
1. Nausea & Vomiting
2. Febrile Neutropenia
3. Myelosuppression
● New symptoms developing during cancer treatment
should always be assumed to be REVERSIBLE until
proven otherwise
● Systemic infections, sometimes with unusual pathogens,
may be a consequence of the immunosuppression
associated with cancer therapy
● A critical component of cancer management is assessing
the response to treatment
● If imaging tests have become normal, repeat biopsy of
previously involved tissue is performed to document
complete response by pathologic criteria
● A COMPLETE RESPONSE is defined as disappearance
of all evidence of disease, PARTIAL RESPONSE is >50%
reduction in the sum of the products of the perpendicular
diameter of all measurable lesions
● PROGRESSIVE DISEASE is defined as the appearance
of any new lesion or an increase of >25% in the sum of
the products of all measurable lesions
● Tumor shrinkage of growth that does not meet any of
these criteria is considered STABLE DISEASE
● NO RESPONSE IS COMPLETE WITHOUT BIOPSY
DOCUMENTATION OF THEIR RESOLUTION
TUMOR MARKERS -
● Measurable; rising and falling levels are usually
associated with increasing or decreasing tumor burden,
respectively
● Can also be used to assess response to treatment
DEPRESSION -
● Recognition and it's treatment are important components
of management
● Incidence is ~25% overall and may be greater in patients
with debility
● It is likely in a patient with depressed mood (dysphoria)
and/or a loss of interest in pleasure (anhedonia) for at
least 2 weeks
○ Appetite change, Sleep problems, Psychomotor
retardation or agitation, Fatigue, Feelings of guilt
or worthlessness, Inability to concentrate, and
Suicidal ideation
● Fluoxetine, Sertraline, Paroxetine and Amitriptyline,
Desipramine (allowing 4-6 weeks for response)
LONG-TERM FOLLOW-UP, LATE COMPLICATIONS
● Site reassessment of tumor by radiography or imaging
techniques
● Regular follow up for disease recurrence
● For many types of cancer, survival for without recurrence
is tantamount to CURE
SUPPORTIVE CARE -
● In many ways, the success of cancer therapy depends on
the success of the supportive care
● QUALITY-OF-LIFE MEASUREMENTS have become
common endpoints of clinical research studies
● A CREDO FOR ONCOLOGY COULD BE TO CURE
SOMETIMES, TO EXTEND LIFE OFTEN, AND TO
COMFORT ALWAYS
PAIN -
● Pain occurs with variable frequency in the cancer patient:
○ 25-50% of patient present at diagnosis
○ 33% during treatment
○ 75% with progressive disease
● In 70% of cases, pain is caused by the tumor itself
● Pain therapy should be withheld while the cause of pain is
being sought
NAUSEA -
● Emesis in the cancer patient is usually caused by
chemotherapy
○ Acute emesis
○ Delayed emesis
○ Anticipatory emesis
● ONDANSETRON + DEXAMETHASONE
EFFUSIONS -
● Fluid may accumulate abnormally in the pleural cavity,
pericardium, or peritoneum
● Lung cancer, breast cancer, and lymphomas account for
~75% of malignant pleural effusions
● PLEURAL EFFUSIONS
○ When condition is symptomatic,
THORACENTESIS is usually performed first
○ CHEST TUBE DRAINAGE is required if
symptoms recur within 2 weeks
○ BLEOMYCIN, DOXYCYCLINE, TALC
● PERICARDIAL EFFUSIONS: Creation of pericardial
window, pericardial stripping; sclerosis
● MALIGNANT ASCITES: Repeated paracentesis,
peritoneovenous shunts
APPROACH TO THE PATIENT WITH CANCER 3
 NUTRITION -
● Most patients with advanced cancer experience weight
loss and decreased appetite
● Threshold for nutrition intervention:
○ <10% unexplained body weight loss
○ Serum transferrin < 1500 mg/L
○ Serum albumin < 3.4 g/dL
● Enteral nutrition is preferred over Parenteral nutrition

PSYCHOSOCIAL SUPPORT -
● Patients undergoing treatment experience fear, anxiety,
and depression
● Women who receive cosmetic advice that enables them to
look better also feel better
● DAMOCLES SYNDROME

DEATH AND DYING -

● Most common causes of death in patients with cancer
are:
1. Infection
2. Respiratory failure
3. Hepatic failure
4. Renal failure
● About 70% of patients develop DYSPNEA preterminally
● It is best to speak frankly with the patient and the family
regarding the likely course of disease
● BURNOUT SYNDROME

APPROACH TO THE PATIENT WITH CANCER 4