ROLE OF PRIMARY CARE

PHYSICIAN IN ONCOLOGY

Dr Tushar Vishvasrao Patil

M.D.(Med), D.M.(Onco),
Consultant Oncologist ,
Sahyadri Speciality Hospitals,
30C, Erandawane, Karve Road, Pune
ROLE OF PRIMARY CARE PHYSICIAN

 Diagnosis

 Cancer Screening

 Management of Complications
BREAST CANCER
CARCINOGENESIS- A MULTI
STEP PROCESS
Normal Atypical Local
Hyperplasia Primary Tumor
In situ Invasion

Time Points:
A. Overt non invasive carcinoma
Metastatic sites
B. Onset of local invasion
C. Onset of metastatic dissemination
Breast Cancer Location
 INCIDENCE

Indian statistics:
1 in 22 women have life time risk of developing breast
cancer
SIGNS AND SYMPTOMS
 Signs and Symptoms

Most common:
lump or
thickening in
breast. Often
painless

Discharge Redness or pitting

or of skin over the
bleeding breast, like the
skin of an orange
Change in size
or contours of Change in color
breast or appearance
of areola
ABNORMAL SIGNS AND SYMPTOMS

• Puckering
• Dimpling
• Retraction
• Nipple discharge
• Thickening of skin or lump or “knot”
• Retracted nipple
ABNORMAL SIGNS AND SYMPTOMS

Symptoms related to distant disease:

1.Bone pains

2.Jaundice

3.Cough/ hemoptysis

4.Severe headache/vomitting/seizures/
drowsiness
 CLINICAL EXAMINATION

• Performed by doctor or
trained nurse practitioner
 Breast Disease
IMAGING

• MAMMOGRAPHY
– 2 Views
– Magnification

• ULTRASOUND

• MRI
 Mammography
• X-ray of the breast
• Has been shown to save
lives in patients 50-69
• Data mixed on
usefulness for patients
40-49
• Normal mammogram
does not rule out
possibility of cancer
completely
 Mammography Equipment

16
 MAMMOGRAPHY

• Use a low-dose x-ray system to examine

breasts
• Digital mammography replaces x-ray film by
solid-state detectors that convert x-rays
into electrical signals.
• Mammography can show changes in the breast
up to two years before a physician can feel
them

17
 MAMMOGRAPHY
BIRADS (Breast Imaging Reporting and Data systems)
Categories:
0. Need Additional Imaging Evaluation and/or Prior
Mammograms For Comparison
1. Negative
2. Benign Findings
3. Probably benign: short interval follow up recommended.
The risk of malignancy is <2%
4. Suspicious abnormality: Core needle biopsy should be
considered
5. Highly suggestive of malignancy. 95% chance.
6. known biopsy proven malignancy.
Lipoma
Fibroadenoma
Cystosarcoma Phylloides
Carcinoma
Comedo Carcinoma
Ductal Carcinoma
Carcinoma
 Breast Cancer
Mammographic Screening
Mortality
Age ACS NCI Reduction

40 – 49 Q 1 yr Q 1-2 yrs 17%

50 – 69 Q 1 yr Q 1 yr 25 – 30%

70+ Q 1 yr Q 1 yr ?
BREAST CANCER
SCREENING
 BREAST SCREENING
CONSIDERATIONS

1.BREAST SELF EXAMINATION

2.CLINICAL BREAST EXAMINATION

3.MAMMOGRAM
 Breast Self Examination
• Considered optional in all risk groups
because data has shown that instruction in
BSE has no effect on reducing breast
cancer mortality.
 May detect interval cancers between
routine screenings and, therefore, should
be encouraged.
 Premenopausal women may find BSE
most informative when performed at the
end of menses.
 RISK STRATIFICATION
Women at normal risk
• For women between ages 20 and 39
years, a clinical breast examination every
1 to 3 years is recommended, with
periodic BSE encouraged.
• For women ages 40 and older, annual
clinical breast examination and screening
mammography are recommended, with
periodic BSE encouraged.
 RISK STRATIFICATION
Women at Increased risk
1.prior thoracic irradiation
2.Women Aged 35 Years or Older with a 5-Year
Risk of Invasive Breast Carcinoma Greater
Than or Equal to 1.7%
3.Women with a Strong Family History or Genetic
Predisposition
4.Women with LCIS or Atypical Hyperplasia
5.Women with history of breast cancer
 RISK STRATIFICATION
Prior thoracic irradiation
• Annual clinical breast examination
• Periodic self breast examination
Women Aged 35 Years or Older with a 5-
Year Risk of Invasive Breast Carcinoma
Greater Than or Equal to 1.7%
• clinical breast examinations every 6 to 12
months and annual mammography are
recommended, and periodic BSE is
encouraged
 RISK STRATIFICATION
Women with a Strong Family History or
Genetic Predisposition
• Clinical breast exams every 6- 12 months
and annual mammograms beginning at
age 25.
• Women with h/o breast cancer in family or
strong genetic predisposition≥ 25 yrs
should have clinical breast exams every 6-
12 months and annual mammograms
starting 5-10 years prior to the youngest
breast cancer case in the family.
 YOU CAN SPREAD THE WORD
AMONGST ALL YOUR PATIENTS ,
THEIR AQCUAINTAINCES AND
RELATIVES REGARDING SCREENING

YOU ALL CAN MAKE A WHOLE LOT OF

DIFFERENCE TO THE SCENARIO OF
BREAST CANCER IN INDIA!!!
CERVICAL CANCER
CERVICAL CANCER SCREENING
 WHY?
• Risk factors are
– early age of sexual intercourse,
– multiple sexual partners,
– poor sexual hygeine,
– HPV subtypes 16,18 , 31, 33 – Preventable

• Early diagnosis and treatment- possible

with good patient outcomes
• Simple Tools (PAP smear) available
• HPV vaccine available
 CERVICAL CANCER SCREENING

RECOMMENDATIONS
• should begin approximately 3 years after the onset of
vaginal intercourse.
• Screening should begin no later than 21 years of age.
 SCREENING INTERVAL

• Should be performed annually with

conventional cervical cytology smears
• every 2 years using liquid-based cytology;
• at or after age 30, women who have had 3
consecutive, technically satisfactory
normal/negative cytology results may be
screened every 2-3 years (unless they have
a history of in utero DES exposure, are
HIV+, or are immunocompromised).
 HPV VACCINE

• Gardasil (Merck): HPV 16, 18, 6, 11

– Schedule: 0, 2, 6 months IM injections
• Cervarix (GSK): HPV: 16, 18
– Schedule: 0, 1, 6 months, IM injections
LUNG CANCER
LUNG CANCER SCREENING
 LUNG CANCER SCREENING

• Screening for Lung Cancer with Chest X-Ray

and/or Sputum Cytology

• Screening for Lung Cancer with Low-Dose Helical

Computed Tomography (LDCT)
LUNG CANCER SCREENING

PRACTICE GUIDELINES

– Clinical practice guidelines issued by the

American College of Chest Physicians in 2007
recommended against routine screening for
lung cancer because of a lack of evidence that
such screening was effective.
SOLITARY PULMONARY
NODULE
 SOLITARY PULMONARY
NODULE
• Single spherical lesion <3 cm in diameter that is
completely surrounded by lung without
associated atelectasis or adenopathy.

• The critical distinction between SPNs and lung

masses is that the probability of cancer in lung
masses (lesions larger than 3 cm) is high enough
that they warrant a different diagnostic and
treatment approach.
• In the case of solitary pulmonary nodules (< 3
cm), the probability of malignancy varies
considerably.
 SOLITARY PULMONARY
NODULE
• 1st step: review all previous CXR and CT
• Radiographic stability for more than 2 years-
no further diagnostic evaluation is warranted.
• Growth Rate: doubling time
30-400 days
<30 days: infection,
>400 days: most likely benign
• Patterns of calcifications:
1. Benign: central, diffuse, laminar, concentric or
popcorn patterns- no further evaluation is
warranted.
2. Eccentric/stippled pattern: cautious approach
 SOLITARY PULMONARY
NODULE
• Border characteristics:
1. Irregular edge or corona radiata (numerous
strands radiating into the surrounding lung)
may indicate a bronchogenic carcinoma.
2. A well-defined, smooth, nonlobulated edge
may indicate a benign lesion or metastasis,
whereas lobulation and notching may
indicate bronchogenic carcinoma.
 SOLITARY PULMONARY
NODULE
3. Cavitation with a thin, smooth wall may
indicate lung abscess or a benign lesion,
whereas thick-walled cavitations imply an
underlying malignant neoplasm.

4. The CT halo sign (i.e., ground-glass

attenuation surrounding a nodule on CT
scan image) most commonly indicates
infection with an invasive Aspergillus
species. Other less common possibilities
include TB, cytomegalovirus infection, or
herpes simplex infections.
 SOLITARY PULMONARY
NODULE

• Many nodules will not be calcified and often

there will be no old records to review. After a
standard evaluation that includes a CXR and CT
scan, up to 75% of patients will fall into this
indeterminate category.
• For these indeterminate nodules, it is useful to
categorize the decision alternatives into three
primary categories: watchful waiting, performing
a diagnostic test(s), or proceeding to video-
assisted thoracoscopic surgery (VATS) and
possible lobectomy.
 SOLITARY PULMONARY
NODULE

Estimating the Probability of Malignancy

• Risk factors associated with an increased
probability of malignancy include increasing
nodule size, increasing patient age, smoking
history in pack years, being a current smoker as
compared with a former smoker, and having a
history of cancer.
• Radiographic signs associated with malignancy
include nodule margins that are characterized by
the corona radiata sign or a spiculated
appearance.
 SOLITARY PULMONARY
NODULE

• Factors associated with a decreased probability

of malignancy include nonsmoking status, young
age (< 45), benign calcification patterns, nodule
margins that are smooth, and nodules that have
an enhancing rim sign.
SOLITARY PULMONARY
NODULE
 SOLITARY PULMONARY
NODULE
Watchful Waiting

• Is predicted on several key assumptions

• The first of these is that nodule growth rate,
measured radiographically.
• The volume doubling time of malignant
bronchogenic tumors is usually in the range of 30
to 400 days.
• The use of 2-year stability on CXR is predicated on
the assumption that doubling times greater than 2
years are rarely seen in malignant lesions.
 SOLITARY PULMONARY
NODULE
Watchful Waiting
• Involves doing serial imaging studies to follow a
nodule over time, at 3-month and then at 6-
month intervals. If there is evidence of nodule
growth, biopsy or resection is usually
warranted.

• The limit of detectable changes using a

standard CXR is approximately 3.0 to 5.0 mm,
whereas CT scan has a resolution of 0.3 mm,
serial CT scans are rapidly replacing CXR in
the watchful waiting strategy.
SOLITARY PULMONARY
NODULE
Diagnostic Testing
 SOLITARY PULMONARY
NODULE
Summary of Recommendations

• For patients with an SPN that is visible on CXR, all

previous CXRs should be reviewed.
• For all patients with previous CXRs, an SPN that is
unchanged for >2 years does not require further
diagnostic evaluation.
• For patients with an SPN visible on CXR in which
benign central calcification is present, no further
diagnostic evaluation is necessary.
 SOLITARY PULMONARY
NODULE
• A spiral CT of the chest with contrast is indicated to
better characterize the nodule, parenchyma, and
mediastinum.
• For patient with an SPN < 1 cm in size, PET
scanning is not currently recommended.
• For patients with an SPN, if PET scanning with
FDG results are negative, a repeat CT scan is
required at least once in 3 months.
• For the patients with an SPN who are operable
candidates, TTNA is not indicated.
 SOLITARY PULMONARY
NODULE
• For operable patients with an SPN who decline
surgical intervention, TTNA or transbronchial
needle biopsy is the preferred procedure for
establishing a diagnosis.
• For patients with an SPN who are not operable
candidates, or are at high risk, TTNA may be
helpful to establish tissue diagnosis.
• For operable patients with an SPN, a wedge
resection is the procedure of choice followed by
a lobectomy if the pathologic finding is positive
for cancer
 SOLITARY PULMONARY
NODULE

• For operable patients with an SPN, if the lesion is not

amenable to a wedge resection, a diagnostic
lobectomy is acceptable.

• All pulmonary resections must include a systematic

lymph node dissection.

• For patients with an SPN without a definitive tissue

diagnosis, a minimum follow-up of 2 years is
recommended. This should include an initial CXR,
and CT scanning at 3, 6, 12, and 24 months.
 SOLITARY PULMONARY
NODULE

Evaluation of Patients With Pulmonary Nodules: When Is It Lung Cancer?* ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) Chest
2007;132;108S-130S
Evaluation of Patients With Pulmonary Nodules: When Is It Lung Cancer?* ACCP Evidence-
Based Clinical Practice Guidelines (2nd Edition) Chest 2007;132;108S-130S
SUPPORTIVE CARE
 SUPPORTIVE CARE

• Pain management-
• Drugs/surgery/anaesthesia/radiation

– Follow the WHO step ladder of pain

– Use of adjunct modalities for pain relief

• Mehanical obstruction/ effusion-

stenting/drainage/pleurodesis
 SUPPORTIVE CARE
• Post chemo nausea/vomitting
– Antiemetics/steroids/hydration/sos admission

• Neutropenia/febrile neutropenia
– Assess need for admission
– Broad spectrum antibiotics (ceftazidime, pip-
taz, meropenem) if admitted
– Search for primary focus ( oral cavity, para
nasal sinus, abdomen, peri anal region)
– Role of G- CSF (filgrastim)
 EMERGENCIES
• Hypercalcemia/SIADH

• SVC Obstruction

• Spinal Cord Compression

• CNS metastases
 o u !! !
a n k Y
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