yang - general principles of cancer treatments

is cancer the leading cause of death in the US?

cancer is the second leading cause of death

heart disease is the first leading cause

in the US, the estimated leading site of new cancer cases in females for the year 2025 is _______

breast cancer

in the US, the estimated leading site of new cancer cases in males for the year 2025 is _______

prostate cancer

in the US, what is the estimated leading site of cancer-related death among female patients in 2025?

lung cancer

in the US, what is the estimated leading site of cancer-related death among male patients in 2025?

lung cancer

cancer incidence rates in women vs men

cancer incidence rises in women and decreases in men

rates 82% higher in women than in men under age 50 in 2021

racial inequalities in cancer mortality

death rates for Native American and Black people are at least 2x higher than White people for many largely preventable cancers

annual mammograms

the American Cancer Society (ACS) recommends that women aged 45 and older should have annual mammograms for breast cancer screening with the option to start screening at age 40 if desired

cancer and age

In 2015, it is estimated that 842,200 (55%) of cancer patients were diagnosed at aged ≥ 65 years. In 2050, we predict that 1,446,000 (63%) of all pts diagnosed with cancer will be aged > 65 years, an increase of 603,800 annual cases from 2015.

US Cancer Health Disparities

• black men have a prostate cancer death rate that is more than double (more than 2-4x) that for men of any other racial or ethnic group

• black women with breast cancer are nearly 40% more likely to die from it compared wot White women with breast cancer

• Black and Latino individuals with lung cancer are 16 and 9% less likely (respectively) to survive 5 years after their diagnosis compared to White individuals

• During 2014-2018, death from all cancers combined were 7.1% higher in countries experiencing persistent poverty compared to counties not experiencing

noteworthy facts for overall incidence and death rates by race

• highest cancer incidence and mortality rates for women: AIAN women (American Indian & Alaska Native)

• highest cancer incidence and mortality rates for men: black men

cancer site death rates by race

• highest mortality for breast cancer: black women

• highest mortality for prostate cancer: black men

leading disease related cause of death among both children and adolescents

cancer

the most commonly diagnosed cancers in children

leukemia

(2nd = CNS & brain)

childhood cancer (0-14 years)

• leukemia (28%) followed by brain tumor (27%)

• new cases: an estimated 9,550 children in 2025

• death: estimated 1,050 in 2025

  • declined by 70%: 1969 (6.5 per 100,000) to 2012 (2.2 per 100,000), largely due to improvements in treatment and high rates of participation in clinical trials

cancer among adolescents (15-19 years)

• brain tumor (22%) followed by lymphoma (19%) and leukemia (13%)

• new cases: estimated 5,140 in 2025

• death: estimated 600 in 2025, declined by 63%

• gaps in practice and knowledge

• continue to slowly increase in adolescents by 0.7% per year

cancer among children and adolescent:

• risk factors (most thought to be due to random cell mutations without external cause)

• postnatal exposure

  • ionizing radiation —> increased risk of leukemia and solid tumors (i.e. brain, bone, thyroid)

  • prior chemotherapy

  • solid organ transplant recipients

• genetic mutations

  • 10% of childhood cancers are associated with specific inherited genetic mutations: TP53 mutation/retinoblastoma

  • genetic syndromes

    • leukemias and lymphomas: Ataxia telangiectasia Syndrome, Down syndrome

• unique development/growing stage

  • ewing sarcoma that usually arises in the bone: most common in adolescents

  • neuroblastoma: most common in children younger than 5 years of age

brentuximab

brentuximab vedotin for pediatric Hodgkin’s lymphoma

pediatric cancer patients

• may experience treatment-related side effects long after active treatment (late effects)

  • impairment in the function of specific organs

    • joints or bone problems

    • heart failure

    • strokes

    • cognitive dysfunction

  • secondary malignancies

  • development

• may need to limit therapies for low-risk patients and thus reduce late effects and enhance quality of life for survivors

• when monitoring therapy in children, need to remember age-related differences in measured parameters and large differences in size

  • blood pressure

  • heart rate

• adjust creatinine clearance measurements or estimate to adult size (i.e., per 1.73 m²) to correctly adjust drug doses for renal function in children

  • GFR calculation

treatment terminology-NCI:

• induction

• the first treatment given for a disease

• often part of a standard set of treatment, such as surgery followed by chemotherapy and radiation

• when used by itself, induction therapy is the one accepted as best treatment

treatment terminology-NCI:

• consolidation

• treatment that is given after cancer has disappeared following the initial therapy

• used to kill any cancer cells taht may be left in the body

treatment terminology-NCI:

• maintenance

• treatment is given to help keep cancer from coming back after it has disappeared following the initial therapy

treatment terminology-NCI:

• palliative

• treatment is given to relive symptoms and reduce the suffering caused by cancer and other life-threatening diseases

treatment terminology-NCI:

• salvage therapy

• treatment that is given after the cancer has not responded to other treatments

response terminology-NCI:

• remission

a decrease in or disappearance of signs and symptoms of cancer

response terminology-NCI:

• recurrence

• cancer that has recurred, usually after a period of time during which the cancer could not be detected

• may come back to the same place as the original (primary) tumor or to another place in the body

response terminology-NCI:

• relapse

the return of a disease or the signs and symptoms of a disease after a period of improvement

response terminology-NCI:

• refractory

cancer that does NOT respond to treatment

response terminology-NCI:

• complete responses

the disappearance of all signs of cancer in response to treatment

response terminology-NCI:

• partial responses

a decrease in size of a tumor, or in the extent of cancer in the body, in response to treatment

survival terminology-NCI:

• disease free survival

the length of time after primary treatment for a cancer ends that the patient survives without any signs or symptoms of that cancer

survival terminology-NCI:

• progression free survival

the length of time during and after the treatment of a disease, such as cancer, that a patient lives with the disease but it does not get worse

survival terminology-NCI:

• stable disease

cancer that is neither decreasing nor increasing in extent or severity

curative goal of therapy

• goal is to completely eradicate the malignancy or malignant cells

• Hodgkin’s disease, testicular cancer, stage I-III breast cancer

palliative goal of therapy

• goal is to slow disease progression, lengthen survival

• metastatic (stage IV) of any malignancy

“pillars” of cancer treatment

• surgery (ancient times - present)

• radiotherapy (1890s - present)

• cytotoxic chemotherapy (1940s - present)

• precision therapy (1990s - present)

• immunotherapy (1990s - present)

performance status

Eastern Cooperative Oncology Group (ECOG)

• 0 —> full active, able to carry on all pre-disease performance without restriction

• 1 —> restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, like light housework or office work

• 2 —> ambulatory and capable of all self-care but unable to carry out any work activities

• 3 —> capable of only limited self-care, confined to bed or chair >50% waking hours

• 4 —> completely disabled; can NOT carry on any self-care; totally confined to bed or chair

• 5 —> dead

neoadjuvant therapy

• treatment given as a first step to shrink a tumor BEFORE the main treatment, which is usually surgery, is given

• potentially organ-sparing

adjuvant therapy

• treatment given AFTER the primary therapy (usually surgery) or concurrent with other therapy (usually radiation) to eradicate residual disease and reduce recurrence

• may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, immunotherapy, or biological therapy

what is a chemotherapy cycle?

definition of a cycle depends on the regimen

• named after the initials of the dugs used in the treatment

• R-CHOP

  • Rituximab

  • Cyclophosphamide

  • Hydroxydaunomycin (doxorubicin)

  • Oncovin (vincristine)

  • Prednisone

traditionally administered combination regimen of IV cytotoxic chemotherapy every 3-4 weeks

• R-CHOP every 21 days

  • D1: rituximab, cyclophosphamide, doxorubicin, vincristine

  • D1-5: prednisone

  • cycle 1 D22 = cycle 2 D1

minimum hematology values prior to chemotherapy administration

• after nadir

  • ANC > 1500 cells/mm³

  • WBC > 2000 cells/mm³

  • platelet > 100,000 cells/mm³

  • hemoglobin (Hgb) > 9g/dL

• renal and hepatic function

• patients enrolled in a clinical study

  • varied based on study inclusion/exclusion criteria;

    • ANC > 750 cells/mm³

dose-intense chemotherapy

higher dose, same interval between cycles

dose-dense chemotherapy

aims to achieve maximum tumor kill by increasing the rate of chemotherapy delivery, NOT by increasing dosage

• requires growth factors such as G-CSF to accelerate recovery from neutropenia

precision medicine

• Is broadly defined as treating a patient based on characteristics that
  distinguish that individual from other patients with the same disease.

  • The molecularly targeted therapeutics that are the foundation of precision medicine

    • Based on the genetic, molecular, and cellular changes that underpin cancer biology

  • Increasing number of therapeutics that more precisely target specific
    molecules involved in the development and progression of cancer

    • Tend to be more effective and less toxic than the mainstay of cancer care for decades—radiotherapy and cytotoxic chemotherapy.

• Example: vemurafenib

  • melanoma patients carrying Braf V600E mutant

complimentary medication

• According to NCI

  • Complication medicine refers to treatments that are used alongside standard medical treatment, but they are not themselves considered standard treatments

    • Acupuncture

    • Yoga

    • Ginger

    • Relaxing acupressure

• Benefits

  • Reduce certain adverse effects of chemotherapy and radiotherapy

    • Fatigue, nausea, sleep disturbance, anxiety, joint pain etc.

pallitative care

• extra layer of support to patients with serious illness such as cancer and their families

• NOT the same as hospice care

• addresses many challenges that can affect quality of life after cancer diagnosis:

  • emotional challenges

  • physical symptoms and adverse effects

  • practical challenges

  • spiritual challenges

• any health care provider can provide primary palliative care

• any pt diagnosed with serious illness and their family and friends can receive palliative care

• can be provided in hospital setting (majority), at home, over the phone, or outpatient