Oncology Basics: Staging, Intent, MDTs, Screening & Survivorship

Overview of This Lecture Series and Today’s Focus

The oncology block is being rearranged into three introductory lectures (delivered by Dr Jovo) and one on palliative care (delivered later by Dr Berger). Because the discipline is vast, the first three talks concentrate on foundational language, staging principles, modes of therapy, and the organisation of cancer care; only illustrative diseases are examined in depth. During the coming rotation (an “X-block” lasting only a few days) students will observe these principles applied in real clinics and radiotherapy suites.

Why Staging Sits at the Core of Oncology

Staging determines where a malignancy began, how far it has extended locally, whether nodal basins are involved, and whether tumour cells have reached distant organs. These facts:

1. Allow clinicians anywhere in the world to use a shared “diagnostic shorthand” when they report cases.
2. Dictate the standard‐of‐care protocol (surgery first? chemotherapy alone? radical radiotherapy?) for that exact anatomic and biologic situation.
3. Provide prognostic information such as overall survival (OS) and disease-free survival (DFS).
4. Decide which clinical trials a patient may legitimately enter.

The TNM System (Used for Most Solid Tumours)

• T = ‘Primary Tumour’. Assessed by size OR depth of penetration, depending on organ.
• N = ‘Regional Nodes’. Counts or groups involved draining nodes.
• M = ‘Distant Metastasis’. $M<em>0$ = none; $M</em>1$ = present (sub-coded $M<em>{1A},M</em>{1B},M_{1C}$ when multiple organs are involved).
When all three components are known, they are combined into a “composite stage group” – Stage 0 (in situ) through Stage IV. Letters are appended when several different T/N patterns map to the same numeral (e.g. $ext{Stage III A}, ext{III B}$).

Special notes:
• Regional nodes are those recognised anatomical basins that drain the primary organ. Nodes outside that drainage field, even if still nodal tissue, are coded $M_1$.
• A solitary, very small in-situ focus with no basement-membrane breach is Stage 0 no matter the organ.

Worked Examples from the Lecture

1. Colorectal cancer (depth-based T):
    • $T<em>{in situ}$ – epithelium only.  • $T</em>1$ – invasion into submucosa.
    • $T<em>2$ – tumour breaches muscularis propria.  • $T</em>3$ – extends through serosa.
    • $T<em>4B$ – invades adjacent organs.  N-category depends on the absolute number of positive nodes: one = $N</em>1$; two or three = $N<em>2$; more than three = $N</em>3$.
    Visceral deposits in liver + bone would be coded $M_{1C}$ (≥2 organs).

2. Breast cancer (size-based T):
    • <2 cm → $T<em>1$; 2–5 cm → $T</em>2$.
    • Fixation to chest wall/skin → $T<em>4$.  • 1–3 axillary nodes → $N</em>1$; 4–9 → $N<em>2$; ≥10 or infraclavicular → $N</em>3$.
    • No distant spread = $M<em>0$; any distant focus (even tiny) = $M</em>1$.

Organ-Specific Alternatives to TNM

• FIGO system – international standard for cervical carcinoma: Stage I (confined to cervix) up to Stage IV B (distant haematogenous spread). Bladder or rectal wall invasion is Stage IV A.
• Ann Arbor system – lymphomas: Stage I/II above diaphragm, Stage III both sides, Stage IV disseminated marrow/extra-nodal; suffixed “A” (no B-symptoms) or “B” (fever, night sweats, weight loss).
Such variants respect the biology of particular tumours and sometimes incorporate systemic symptoms directly into stage.

Differential Diagnosis: Never Assume ‘Cancer’ Until Proven

Clinicians formulate a list of plausible aetiologies sharing the same presentation. The lecture suggested the VINDICATE mnemonic (Vascular, Inflammatory/Infective, Neoplastic, Degenerative, Idiopathic/Iatrogenic, Congenital, Autoimmune/Allergic, Traumatic, Endocrine/Environmental). Investigations then sequentially rule candidates in / out until one definitive histopathological diagnosis remains.

The Multidisciplinary Team (MDT)

Historically adopted in the 1980s, MDT meetings gather:
• Clinical/Radiation/Medical oncologists
• Surgeons of the relevant speciality
• Radiologists
• Pathologists and molecular scientists
• Genetic counsellors, dietitians, social workers, psychologists
Decisions cover staging confirmation, best-evidence therapy, eligibility for clinical trials, sequencing of modalities, and a follow-up schedule. Meta-analyses show MDT discussion improves overall survival and reduces practice variation.

Distinction:
• Multidisciplinary = parallel, discipline-specific opinions that are later collated.
• Interdisciplinary = real-time integrative discussion including patient/family, with flexible leadership and shared execution of plans.

Intention of Treatment: Radical (Curative) vs Palliative

RADICAL = aims at eradication of all malignant cells and long-term survival. Multiple modalities are often sequenced: e.g. neoadjuvant chemotherapy → surgery → adjuvant radiation ± hormonal therapy. Side-effect tolerance thresholds are higher; follow-up is intense.

PALLIATIVE = aims primarily at symptom control and quality of life when cure is biologically implausible (usually Stage IV or patients with prohibitive comorbidities). Single, well-tolerated modalities are preferred to avoid cumulative toxicity. Treatment may still prolong life but length is a secondary metric.

Remission is defined as being cancer-free for ≥5 years after curative-intent therapy. Metastatic disease, even if dormant, is not classified as “in remission”; the language switches back to control or palliation.

Palliative Care – A Human Right

Palliative care teams (physicians, nurses, pharmacists, social workers, clergy) relieve “total pain” – physical, psychological, social, spiritual – without accelerating or delaying natural death. Services can and often do run concurrently with curative treatment whenever symptom burdens warrant it. Dr Berger’s later lecture will elaborate.

Screening, Prevention, and Early Detection

Rationale: cancers discovered in a pre-symptomatic or localised state are far more likely to be radically curable. Levels of prevention:
• Primary – eliminate risk factors or infectious agents (HPV vaccination, smoking cessation, lifestyle change, voluntary medical male circumcision).
• Secondary – find occult disease through organised programmes.

Key South African/WHO‐endorsed tests:

1. Cervical: HPV DNA assay (gold standard), cytology (Pap smear), or VIA (visual inspection with acetic acid).
2. Breast: patient self-exam, clinical breast exam, mammography (low-dose X-ray).
3. Prostate: serum PSA with digital rectal examination (DRE); note controversies around specificity.
4. Colorectal: faecal occult blood test (FOBT) or immunochemical test, followed by colonoscopy if positive.

Navigation sequence: individual notices a change → primary care performs initial assessment/biopsy → specialised oncology service finalises staging and enters MDT discussion.

Psychosocial Services and the Role of the Social Worker

Cancer disrupts family economics, employment, sexuality, spirituality, and mental health. Social workers provide:
• Individual or family counselling
• Employer liaison and benefit navigation
• Bereavement support (acknowledging death as a normal life stage)
They routinely attend MDTs to ensure psychosocial plans are integrated with medical ones.

Structured Follow-Up and Survivor Care Plans

Post-radical therapy, patients are reviewed:
• First visit ≈6 weeks after completion.
• Then every 3 months in year 1, spacing to every 6–12 months by year 3.
• After 5 years of disease-free survival some centres discharge, but patient education continues because late recurrence remains possible.

Survivorship domains:

1. Prevention of recurrence and second primaries.
2. Monitoring and management of late toxicities (cardiac, endocrine, fertility).
3. Psychological well-being, sexual function, social reintegration.
4. Legal/insurance/workplace issues.

Key Take-Home Messages

• Staging = $T$ primary, $N$ node, $M$ metastasis; defines treatment, prognosis, and trial eligibility.
• Always build a differential diagnosis before labelling a mass “cancer”.
• MDT deliberation is the evidence-based standard for formulating oncologic care.
• Intent may be Radical (length of life) or Palliative (quality of life); treatments and tolerance thresholds differ accordingly.
• Palliative care principles apply to all life-limiting illnesses and should be offered early.
• Systematic screening (Pap smear/HPV testing, mammography, PSA, FOBT) plus behavioural risk reduction constitutes effective prevention.
• Social work and psychology are indispensable; oncology is never purely biomedical.
• Survivorship planning starts the moment treatment ends and extends for life.