Cancer II: Staging & Grading, Cancer Treatments, and Adverse Effects (3)

KIN 3535 Final Exam (3)

Screening

• testing for disease (or risk factor) in asymptomatic population

• may play a role in primary intervention

• objectives: early detection

• not a firm diagnosis

Genetic screening

testing for inherited genetic mutations

Population screening programs

testing for highly prevalent cancers

not diagnostic

Screening tests are _________

histology

Diagnosis is confirmed with ___________ (tissue/cell appearance examination)

Stage

______ of disease is confirmed by pathologist using histological and imaging techniques to determine extensiveness [EXTENT of disease or SIZE of tumor]

Grade

_______ of disease refers to histopathological features related to aggressiveness [BEHAVIOR of cancer cells or disease AGGRESSIVENESS]

T

describes the size and extent of the tumor

• it can be between 1-4

• the higher the number, the greater the size and extent

• 0 = carcinoma in situ (in its original place)

N

describes whether cancer has spread to lymph nodes

• it can be between 0-3

• the higher the number, the more lymph nodes are affected

• 0 = no involvement of lymph nodes

• 1 = 1-3 lymph nodes are affected

• 2 = 4-9 lymph nodes are affected

• 3 = 10+ lymph nodes are affected

M

describes whether the cancer has metastasized (from the primary tumor to other parts of the body)

• it can be 0 or 1

• 0 = no metastasis

• 1 = metastasis present

staging

TNM _________ System:

• T = tumor

• N = nodes (lymph nodes)

• M = metastasis

Ex. T2N1M0 (stage 2 disease with up to 3 lymph nodes affected with no metastasis)

Stage I

T = <2 cm

N = none

M = none

Stage II

T = 2-5 cm

N = no or yes

M = none

Stage III

T = >5 cm

N = yes

M = none

Stage IV

T = does not matter

N = does not matter

M = yes

Differentiation

refers to how cancer cells look and function compared to normal cells

low grade

slower growing, well-differentiated

high grade

more aggressive, faster growing, poor differentiated

G1

Well-differentiated

Low risk

G2

Moderately differentiated

Intermediate risk

G3

Poorly differentiated

High risk

G4

Undifferentiated

High risk

Neo-adjuvant

prior to primary treatment to improve primary treatment/overall success

Curative/Primary treatment

intention is to cure the cancer

Adjuvant

after primary treatment (to improve overall success)

Palliative

intention is to slow progression, reduce disease burden, control the disease (may or may not extend life)

treatment decision

Factors affecting ____________

• disease profile (type, stage, grade)

• age

• treatment (side effect) tolerance

• socioeconomic status

• overall health

  • comorbidities

  • psychosocial health

  • physical fitness

Treatment options

• active surveillance

• surgery

• radiation

• ablation (cryo/laser)

• chemotherapy

• hormone therapy

• targeted therapy

• supportive care

Active surveillance

a disease management plan for early stage, low grade cancers that does NOT treat disease but instead involves active monitoring of the disease without exposing patients to the adverse effects of treatment until necessary (when there are changes in test results that show the condition is getting worse)

reduce overtreatment

What is the purpose of active surveillance?

Overtreament

unnecessary treatment for a condition that is not life-threatening or would never cause any symptoms. May lead to problems and harmful side effects

Adverse effects of active surveillance

• cancer-specific anxiety

• fear of disease progression

• low emotional well-being

Surgical oncology

• preventative

• diagnostic

• curative (removal of primary cancer)

• reduce the bulk of the tumor (debulking)

• palliative

• restorative or reconstructive

Surgery

• foundation of curative therapy

  • 30% cure with this alone

  • employed in 60% of all cancer diagnoses

• the tumor, along with the adjacent healthy organ tissue and lymph nodes, is typically removed to offer the best chance for cure

• margins are assessed for disease presence

Types of surgery

• open (invasive)

• minimally invasive:

  • laparoscopic

  • robotic-assisted

Open surgery

cutting of skin and tissues so surgeon has full view of structures and organs

Laparoscopic surgery

a minimally invasive technique where operations are performed through small incisions using a camera and specialized instruments

Robotic-assisted surgery

• has lower complications compared to open

• higher psychosocial, physical, and sexual well-being following surgery

• length of hospital stay after surgery is shorter

• overall survival is similar to open surgery

Adverse effects of surgery

• local/organ-specific dysfunction

• scarring and other changes to appearance

• reduced functional capacity

• infection/other complications

• lymphedema

• numbness

• fatigue

• pain

• reduced HRQOL

Radiation oncology

a medical specialty within oncology that involves treating cancer with radiation

Radiotherapy

a type of ionizing radiation that damages the DNA of cancer cells (but can also affect normal cells)

Ionizing radiaiton

a form of energy that removes electrons from atoms and molecules of materials that include air, water, and living tissue

External beam radiation

• local treatment

• delivered radiation targeting the tumor site

• painless

• people who receive this are NOT radioactive

Brachytherapy

• local treatment

• radioactive seeds are placed inside or next to the tumor

• it uses a higher total dose of radiation compared to EBM

• less damage to healthy tissues than EBM

• people who undergo this are radioactive for the first 3 months. After 8 months, all radiation has been released

Adverse effects of radiaiton

• fatigue

• skin problem (irritated, swollen, dermatitis)

• dry mouth

• difficulty swallowing

• nausea

• low blood count

• headaches

• soreness

• memory problems

• hair loss

• shortness of breath

• stiffness

• loss of appetite

• diarrhea

• incontinence

• sexual dysfunction

Chemotherapy

• treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing

• may be given by mouth, injection, or infusion depending on the type and stage of the cancer being treated

• can be given as primary curative, palliative, neoadjuvant, adjuvant

• may be given alone or with other treatments, such as radiation or immunotherapy

Chemotherapy schedule

• sessions are given according to a schedule that involves treatment typically followed by “rest”

• the entire course MAY last for a total of 3-6 months

• the number of sessions depends on disease and patient-related factors (e.g., extent of cancer, comorbidities, etc.)

• may be a single or a combination of drugs

cytotoxic

Chemotherapy is _________ and affects nearly every cell in the body and does not only target cancer cells, leading to damage in healthy cells

Chemotherapeutic agents

• alkylating agents

• antimetabolites

• anthracyclines or antitumor antibiotics

• alkaloids

Peripheral Neuropathy

most common adverse effect of chemotherapy; tingling pain, numbness of upper and lower limbs

Adverse effects of chemotherapy

• anemia

• appetite loss

• thrombocytopenia

• bruising

• constipation

• diarrhea

• edema

• fatigue

• cardiotoxicity

• fertility issues

• flu-like symptoms

• hair loss

• infection and neutropenia

• memory or concentration problems/”chemobrain”

• peripheral neuropathy

• pain

• skin and nail changes

• sleep problems

• sex and fertility issues

• anxiety

• depression

• mouth and throat problems

• nausea and vomiting

Cancer-related fatigue

• affects 70-100% of patients undergoing treatment

• is the MOST distressing treatment-related symptoms

• 94% of oncologists treat pain; only 5% treat this

• may cause patients to discontinue/reduce treatment

• NCCN recommends exercise/PA for treatment

Pain

• this related to cancer or its treatment affects 50-90% of cancer patients

• tumor or treatment-related

  • surgery, radiation, chemo

• negatively impacts quality of life

• exacerbates fatigue

• is a predictor of survival

Erythrocytopenia

low red blood cell count

• compromised O2 delivery (anemia)

Leukopenia/neutropenia

low white blood cell count

• compromised immune system

Thrombocytopenia

low platelet count

• compromised blood clotting

Lymphatic system

• network of vessels that transport immune-cell rich fluid to facilitate immune response

• it is often a primary site for metastasis

• lymph nodes can often be removed, destroyed, or damaged during cancer therapy

Lymphedema

swelling due to build-up of fluid in the body tissues when the lymph system is damaged or blocked

• more common in the arms and legs

• can be caused by:

  • a tumor that blocks the lymphatic system

  • lymph node dissection (i.e., surgical removal of lymph nodes)

  • radiation can damage the lymphatic vessels

• symptoms:

  • pain/discomfort

  • dysfunction/disability

  • infection risk

  • lymphorrhea

  • ulcers/necrosis

Lymphorrhea

abnormal flow of lymph that drains externally from disrupted lymphatic vessels or is retained within a wound

Lymphedema treatments

• assessment by lymphedema specialist (decongestive therapist)

• elevation

• compression garments/wraps (20-30 mmHg)

  • conflicting evidence regarding necessity for compression garments during exercise)

• lymph drainage therapy (complete decongestive therapy)

• surgery

Depression

• is a common result of cancer and its treatments

• 20-50% of patients with cancer experience this

Anxiety

• 1/5 patients have clinical levels of this

• nearly 1 in 4 patients have subclinical levels of this