Oncology

Locally confined disease can be managed with breast-conserving surgery and radiotherapy, or modified radical mastectomy. Adjuvant therapy in early-stage disease may be either systemic chemotherapy or hormonal therapy. Treatment with adjuvant chemotherapy is dependent on the lymph node status, tumour size, histology of the tumour, hormone receptor status, and age and menopausal status of the patient.

Advanced-stage cancer could be locally advanced large tumours, those with significant nodal or cutaneous spread, recurrent cancer or metastatic disease. A decision to treat aggressively in a patient with good performance status who has locally advanced tumour would require multimodality combination therapy. This would include induction chemotherapy followed by loco-regional therapy in the form of surgery and/or radiotherapy. Inflammatory breast cancer is another form of locally advanced breast cancer that requires aggressive systemic and loco-regional therapy. High-dose chemotherapy with autologous stem cell transplantation has not shown any significant benefit over conventional therapy, and should therefore be considered only in the setting of a clinical trial. Younger patients with oestrogen-receptor-positive disease may benefit from oophorectomy or chemical castration with luteinising hormone receptor agonists. Other options of therapy in metastatic disease include tamoxifen, palliative chemotherapy or combination therapy.

Screening of other first-degree female relatives of a young patient with breast cancer is a contentious issue and may be a subject of discussion at the examination. The implications of such screening should be discussed with the family members and the choice should be offered, if appropriate.

An older patient with multiple medical problems may also have a diagnosis of prostate cancer. In such a situation it is important to identify the relative importance of the prostate cancer in the patient’s clinical context. Ask about the initial diagnosis and the presenting symptoms. Some patients may present with prostatic symptoms such as frequency, urgency, hesitancy, urinary retention, or with urinary tract infection.

Initial diagnosis is made by digital per rectum examination or measurement of serum PSA levels (case finding). In the physical examination look for surgical scars and radiotherapy tattoos. Do not forget to look for gynaecomastia and bone tenderness.

Clinical as well as pathological staging will determine the appropriate therapeutic approach. Other factors that influence the management approach include the patient’s functional capacity, age, other comorbidities and patient expectations.

Locally advanced disease and recurrent disease together with metastatic disease have a worse prognosis. Palliative management of widespread disease is with androgen deprivation therapy and radiotherapy for painful bony metastases. Androgen deprivation also helps reduce bone pain and also effect some primary and secondary tumour regression. Even hormone-responsive tumours may become hormone refractory after a period of time (usually within 2 years). Attempts at managing hormone-resistant disease can be made with palliative radiotherapy, IV strontium-89 and chemotherapy with mitozantrone.

For non-small-cell cancer of stages I and II, where the disease is confined to the lung or has spread only to ipsilateral peribronchial or hilar lymph nodes, surgical intervention in the form of lobectomy or pneumonectomy is indicated as a curative measure. Upon curative therapy, patients need surveillance every 3 months, with clinical assessment and a chest X-ray if indicated, for 2 years, and thereafter every 6 months for up to 5 years. Screening should continue annually thereafter.

Small-cell lung cancer behaves in a very aggressive manner—it has a rapid doubling time and a propensity to spread widely within a very short period of time. Small-cell lung cancer is staged as either limited disease, where the disease can be encompassed in a single radiation field, or extensive disease, where there is metastatic disease or the involvement of the contralateral supraclavicular nodes, pleural effusion or pericardial effusion. This tumour is highly responsive to chemotherapy as well as radiotherapy. However, terminal and therapy-refractory recurrence happens within the first 2 years. Limited-stage disease is usually treated with a platinum-based agent and etoposide, where the life expectancy is expected to increase to about 18 months. The untreated patient has an average life expectancy of 9–12 months. In addition, the patient should be offered mediastinal radiotherapy and prophylactic cranial irradiation. Metastatic disease, too, can be treated with palliative gentle chemotherapy, but the prognosis is usually grave. Many patients may also manifest paraneoplastic syndromes with neurological features (e.g. Lambert-Eaton myasthenic syndrome), SIADH or Cushing’s syndrome.

Colon cancer is a common malignancy and a leading cause of death. Ask about the initial presentation. Most patients present with abdominal discomfort of varying degree, altered bowel habits (chronic constipation followed by spurious diarrhoea), melaena and per rectal bleeding. The patient may also have constitutional symptoms of malignancy, such as weight loss, weakness and lethargy, and features secondary to anaemia. Significantly advanced disease can present with bowel obstruction, bowel perforation or neurological symptoms due to the spread to the pelvic nerves. Advanced cancer can also present with regional lymphadenopathy or hepatic metastasis. Check for any family history of colon or other cancer. Familial adenomatous polyposis and hereditary non-polyposis colon cancer are genetic risk factors for colon cancer with an onset at a younger age. A history of ulcerative colitis is a definite risk factor for colonic cancer. Other risk factors include high alcohol consumption, obesity and diabetes. Ask about staging investigations and treatment so far. Ask how the patient manages the colostomy if relevant.

Look for evidence of generalised wasting, cachexia and features of anaemia. Perform a thorough abdominal examination and clearly define any mass lesions by location, magnitude, mobility and consistency. Exclude hepatomegaly and ascites. Look for lymphadenopathy by drainage zone. Look for obvious or occult blood in the rectal examination. Look for pigmented lesions in the buccal mucosa that may suggest Peutz-Jeghers syndrome, which is a risk factor for colon cancer. Look in the colostomy site for evidence of inflammation or infection.