Clinical assessment

When taking a history and examining a patient who might have cancer it is useful to remember that the disease may present in several ways (Table 6.3).

Table 6.3 Presentations of malignant disease

Investigation and diagnosis

Investigations should include FBC, U&E, LFTs, urine cytology, plain X-ray, e.g. chest X-ray, serum tumour markers.

Complex investigations, determined by the suspected diagnosis, include ultrasound, CT, MRI, PET, PET-CT and contrast radiology of the GI tract (now superseded by endoscopy, laparoscopy and thoracoscopy).

A pathological diagnosis is essential prior to treatment. This may be achieved by aspiration cytology, done by passing a fine needle into the lesion and applying suction with a syringe. Small fragments are drawn into the barrel and can be extracted and stained for examination under the microscope, giving an assessment of the shape and features of individual cells. Needle biopsy produces a tissue core which is processed and sectioned, providing a histological examination showing the pathological architecture. Open biopsy, either incisional or excisional, confirms the diagnosis. All the above methods may be undertaken under X-ray, ultrasound or CT guidance.

Tumour staging

Staging of a tumour is an attempt to quantify how advanced a cancer has become at the time of diagnosis. Many systems have been devised for different organs and are detailed in the specific chapters. The TNM (tumour, nodes, metastases) system (Box 6.1) is now more widely adopted. This may be divided into a clinical staging or, after pathological assessment, a pathological system (pTNM classification). This system is being constantly updated (the latest revision is TNM7).

Histological grade

Tumour grading is used in conjunction with the TNM to give an assessment of prognosis for the patient (Table 6.4). It also permits evaluation of the efficacy of different treatments on tumours of comparable stage.

Table 6.4 Histological classification

Operations for cancer

Definitive elective treatment surgically of a tumour is ideally decided on unequivocal histological confirmation and an accurate pre-operative assessment of stage. However, some patients present as an emergency (e.g. carcinoma of the colon) without this information. The aim of surgical management is either curative or palliative.

Increasingly, patients are having systemic and/or radiotherapeutic treatment (e.g. for advanced carcinoma of the rectum) prior to surgery. This is termed neo-adjuvant therapy; the aim being to downstage the tumour.

A curative procedure involves total excision of all the tumour-bearing tissues with associated lymphatic and venous drainage. Invasion of adjacent vital structures may determine feasibility of removing a tumour (its operability). The determination of how far to place the resection away from the visible growth (the resection margin) is described in appropriate sections of this book.

Reconstruction after surgery is an important aspect of surgical technique which aims to enable most patients to regain as near normal a lifestyle and self-perception as possible. This is particularly important in colorectal disease where a stoma may be required, or breast surgery where reconstructions after mastectomy are important for the restoration of body image and confidence. Fully informed consent is needed after detailed discussion with the patient, and a full understanding of the balance between the need to cure the patient of their cancer and the results of surgery in this context.

Adjuvant therapy

Adjuvant therapy is additional anti-cancer treatment used for some patients thought to have had tumours completely removed by surgery. The aim is to destroy occult micro-metastases by chemotherapy, local radiotherapy or a combination of these. Some patients may not need this treatment and the risks of adjuvant treatment need to be borne in mind in this situation. Adjuvant therapy may be given before (neo-adjuvant therapy) or after surgery (Table 6.5). Useful regression of some tumours (e.g. rectum and breast) can be achieved, converting non-operable into operable disease. Many new trials of different regimes are being performed throughout the world to determine the best treatments.

Table 6.5 Adjuvant and neo-adjuvant therapy

Radiotherapy

There are three ways of administering radiotherapy to kill cancer cells:

Radiotherapy acts by inducing chemical changes within the nucleus of the cell that cause damage to DNA. A tumour is therefore depopulated of its malignant cells during mitosis and the number of viable cells present, the intrinsic radiosensitivity of the cells and the mitotic rate determine the efficacy of radiotherapy. Surrounding normal tissues are also damaged by radiation, and those with a high cell turnover are especially susceptible.

The total dose for the tumour is calculated for each individual site and size. Treatment is given in fractions of the total dose, thus minimising unpleasant side effects, for example local soreness, skin changes, lethargy, nausea and vomiting. New super-voltage apparatus is able to deliver increased penetration into deep tissues from various directions, enhancing destruction of tumour cells without damaging surrounding structure.

Side effects of radiotherapy include local soreness, skin changes and burning, lethargy, nausea and vomiting. Pelvic radiotherapy causes cystitis and diarrhoea. Radiation damage to normal tissues may not become apparent for several years (e.g. radiation enteritis, see p. 129).

Cytotoxic chemotherapy

Cytotoxic chemotherapy interferes with cell division in both normal and malignant cells. Success depends on the intrinsic resistance of the tumour cell to the agent and the toxic effects on normal tissues. There are four main types of chemotherapy agents, many of which can be used in combination. Their effects on normal proliferating cells may result in bone marrow and intestinal toxicity.

Endocrine manipulation

Some tumours are dependent on hormones for their normal growth. Endocrine manipulation may effectively inhibit tumour progression. Examples are shown in Table 6.6.

Table 6.6 Examples of endocrine manipulation which may inhibit tumour progression

Prognosis

Prognosis is determined by the stage and grade of the cancer at presentation. Survival is usually expressed as percentage of patients alive after 5 or 10 years. Such data is derived from population studies and it is always impossible to predict life expectancy for an individual patient, only the probability of their surviving a specified time.

Palliative care

When cure is impossible, palliative care must be provided. Full and frank discussion about the prognosis with the patient when treatment for cure fails is essential. Early referral to a team which can provide palliative care helps address the fear of death. Terminal care alleviates the psychological disturbance associated with impending death whilst counselling of the patient and family can help greatly. The aim of terminal care is to try to keep the patient in familiar surroundings, preferably home, whilst providing adequate facilities for analgesia and nursing care.