Oncology

Published on 24/06/2015 by admin

Last modified 24/06/2015

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COMMON MALIGNANCIES

A good grasp of the basic principles of cancer management is expected of all candidates. Identification of common malignancies, staging protocols, evaluation of prognosis and issues of therapy are the major areas of interest.

Approach to the patient

History

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.

Examination

1. Look for cachexia, alopecia, cushingoid body habitus, flat affect and any vascular access devices (e.g. Hickman catheter).

2. Look for radiation dermatitis, radiation burns, radiation tattoos (markings of the radiotherapy field) and surgical scars.

3. Look for organomegaly, particularly in the abdomen, lymphadenopathy and bone tenderness.

4. Define all mass lesions by quoting the exact measurements. With mass lesions, describe the consistency, fixation, mobility of skin above the lesion, temperature and shape.

5. Perform a detailed neurological examination to exclude deficit due to cord compression, cerebral metastases, paraneoplastic phenomena and neurotoxic chemotherapy.

6. Look for evidence of pneumonitis or pulmonary fibrosis in those who have received pulmonary toxic agents, such as cyclophosphamide or busulphan, as well as those who have received thoracic radiotherapy.

7. Check for evidence of cardiac failure in those who have been treated with cardiotoxic agents, such as the anthracyclines.

Investigations

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.

ECOG (Eastern Cooperative Oncology Group) Performance Scale

0. Active with no restriction of performance.

1. Ambulatory and able to attend to light work activity. Unable to carry out strenuous physical activity.

2. Can manage self-care but unable to attend to any form of work activity. Ambulatory for more than 50% of the time while awake.

3. Can manage only limited amount of self-care. Bed-bound for more than 50% of the time while awake.

4. Disabled, with complete inability to attend to self-care. Completely bed bound.

(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)

BREAST CANCER

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.

1. What is the best approach to the management of this case?

2. What investigations are critical to decide on the appropriate plan of management?

3. How is she coping currently?

4. What further information is required to assess her prognosis?

The current screening recommendation for breast cancer surveillance is for all women between the ages of 50 and 70 to have a mammogram every 2 years. A discovery of a suspicious lump on palpation should be followed up with mammography, to further assess its anatomy and pattern of calcification, and ultrasonography, to define its consistency (cystic or solid). This should be followed up with fine-needle aspiration biopsy or core biopsy to obtain a tissue diagnosis. A thorough physical examination should be carried out to exclude any additional lumps in either breast, axillary lymphadenopathy, lymphadenopathy elsewhere, hepatomegaly and bone tenderness. If the lesion is confined to the breast alone, no staging is necessary, or minimal staging is carried out with chest X-ray and liver function tests (especially looking for an elevation of the alkaline phosphatase level) for apparent early disease. If there is evidence of significant nodal involvement at surgery, further staging investigations should be carried out. These include a bone scan and an ultrasound or CT scan of the liver, in addition to chest X-ray and liver function tests.

Management

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.

Early-stage disease

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.