Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Approach to the patient


Treatment-related cancer is becoming common. Ask about immunosuppressive therapy, hormonal agents, past exposure to chemotherapeutic agents and exposure to radiation.
Enquire about chemotherapy, radiotherapy and surgery for the current diagnosis of cancer. Relevant information about chemotherapy includes the agents that have been used (if known), number of cycles the patient has had and is yet to have, any side effects experienced and the response to therapy. Ask about early side effects such as hypersensitivity, nausea, vomiting and oral mucositis, and how these side effects were managed. Other side effects such as hair loss, sepsis due to immunosuppression, debility, fatigue as well as organ-specific toxicity (pulmonary toxicity, hepatotoxicity, cardiotoxicity and bladder toxicity) should be enquired into.
Ask about sperm or ova harvesting in the young patient who has been treated with agents having gonadal toxicity. Ask about adverse effects associated with other therapeutic modalities, such as radiotherapy and surgery. Enquire about the patient’s insight into his or her condition and what expectations they have for the future.
Ask about pain and how it is managed. Ask whether the patient is depressed. Try to gain an insight into their social support network. Check how the patient is coping and whether any professional psychological help has been received.


Investigations should be tailored according to the clinical presentation, location of the malignancy, type of malignancy and the spread. Radiological imaging (X-ray, CT or MRI scan), basic blood tests (full blood count, electrolyte profile), invasive tests (e.g. endoscopy), organ-specific functional tests and tumour markers are other investigations of relevance.
Imaging tests help define the tumour and the staging process. Biopsy and anatomical pathology is important for defining the diagnosis and grading the cancer.
The candidate should be able to discuss the different investigations that need to be performed in the initial diagnostic work-up as well as in the staging process of different cancers.

Curative and palliative management

In discussing therapeutic options, the candidate should demonstrate a good working knowledge of chemotherapy, radiotherapy and surgical management. The candidate should be thoroughly familiar with the different means of monitoring for chemotherapy toxicity and the preventive and remedial steps that have to be taken.
Assess the patient’s performance status, as this has significant influence on the choice of therapy. Performance status is usually described according to the Eastern Cooperative Oncology Group (ECOG) classification system (see box overleaf) or Karnofsky Performance Scale. Patients who score poorly on these scales have poor tolerance to chemotherapy, and consideration should be given to the palliative options. It is important to possess some knowledge of the principles of palliative care, pain management and care of the terminally ill. Suitable patients should be referred to a palliative care service early in the management. Patients with terminal cancer should be referred to a community outreach palliative care service, which would work in liaison with a hospice facility. Hospice care is indicated for patients living in the community or discharged to the community but who require ongoing nursing care and have a life expectancy of less than 6 months. Following is a discussion on the different cancer types likely to be encountered in the long case setting.
(Adapted from Oken M M, Creech R H, Tormey D C et al 1982 Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology 5(6):649–655)
(Adapted from Oken M M, Creech R H, Tormey D C et al 1982 Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology 5(6):649–655)


Case vignette

A 35-year-old woman presents with a painless, hard and immobile lump in her left breast. She has a family history of breast cancer, with her mother having been treated with mastectomy at the age of 56. Since the initial presentation she has had multiple tests and doctors have planned curative treatment. After definitive primary surgery she has had one cycle of chemotherapy so far. She has experienced distressing side effects and is currently feeling very debilitated and depressed.She has taken 3 months off from her job as a computer analyst and she has a 3-year-old daughter who is cared for by her partner.


Management of localised breast cancer is dependent upon the patient’s age, menopausal status, tumour size, axillary lymph node status, hormone receptor status and expression of protein HER2. Localised breast cancer with positive expression of protein HER2 benefits from treatment with humanised monoclonal antibody trastuzumab (Herceptin®). Patients with axillary-node-positive breast cancer should receive adjuvant systemic therapy upon complete local resection of the primary tumour. Premenopausal women have low rates of hormone receptor/protein-positive tumour, and therefore have better response to adjuvant chemotherapy. Older/postmenopausal patients are more likely to express hormone receptors and therefore be more responsive to hormonal therapy; however, they are also less likely to respond to chemotherapy.

Advanced-stage disease

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