Approach to patients with malignancies

Semmelweis University

Internal medicine II. Department

2017.10.17

Approach?Treatment? Cure?

• Stigma

• Fear

• Symptoms not well definite

• Multidisciplinary

• Emotions ?

• Stigma

• Fear

• Symptoms not well definite

• Multidisciplinary

• Emotions ?

Threatening data

WHO information concerning EU states

2000-2010: mortality rates Cardiovascular disease 9,7% ↓ Respiratory disease 5,8% ↓ Malignant disease 7,2% ↑

2008-2010 incidence:

EU28 average 273,6

Hu 1. place 375,4

Cancer: death sentence or chronic

disease?

Of all the common medical diagnoses, cancer probably carries the greatest stigma and is associated with the

most fear.

Why is so agressiv

Six steps to become a cancer ’

1. Grow without a trigger (selfsufficiency in growth stimuli).

2. Don ’ t stop growing (insensitivity to inhibitory stimuli)..

3. Don ’ t die (evasion of apoptosis).

4. Don ’ t age (immortalization).

5. Feed themselves (neoangiogenesis).

6. Spread (invasion and metastasis)

Etiology : DNA level

Cancer :

-genetic disease,caused by the accumulation over time of changes to the normal DNA sequence alterations, loss, or amplification

- question to be answered:

monoclonal or polyclonal

changes are present in one progenitor cell ??

Etiology (???)

RNA viruses

Human T - cell leukaemia virus Leukaemia

HIV (and Epstein – Barr virus) Non - Hodgkin ’ s lymphoma

HIV (and human herpesvirus 8) Kaposi ’ s sarcoma

Hepatitis C virus Hepatocellular cancer

DNA viruses

Human papillomavirus Cervical cancer

Hepatitis B virus Hepatocellular cancer

Epstein – Barr virus Burkitt lymphoma,

Hodgkin ’ s disease,

nasopharyngeal cancer

Bacteria

Helicobacter pylori Gastric cancer, gastric lymphoma

Known genetic alteration

Cowden sy PTEN,SDH Breasr, endometrium,

Melanoma

Colorectal cc

FAP APC Colon

gastric

Small gut

Thyroid gland

Hereditary breast and ovarium

cancer

BRCA1, BRCA2 Breast

ovary

pancreas

Li- Fraumeni p53 breast

adrenocorticoid

brain

sarcoma

Von Hippel- Lindau VHL Clear cell carcinoma

Pheocromocytoma

Neuroendocrin tumor

MEN RET Medullary thyroid cc

When should we think at hereditary disease

Several organs effected

In body doublets both organs effected

Young patient

Tumor not used in that gender (ex.breast cancer in men)

Screening:chance for early diagnosis

Organ yes Examination Level of evidence

Recommendation

Breast over 50 Mammography positive yes

Breast between40-50

Mammográphia Moderatly positive yes

Colorectal over

50

Occult blood test positive yes

Sigmoidoscopy positive yes

Colonoscopy Moderatly

positive

yes

Cervix Cervix cytology positive yes

Chest/lung Radiography NO No

Skin Physical examination

Moderatly positive yes

Screening Organ Precursors Method

Oropharyngeal Leucoplakia Physical examination

Skin Actinic keratosis Physical examination

Oesophagus Barett’s Endoscopy

Colon Adenoma (polypus)

Colonoscopy

Breast LCIS, DCIS Mammography

Collum Intraepithelialis neoplasia

Colposcopy

Steps of diagnosis

Evaluation of sign and symptoms

Data about family members

Anamnestic data

Physical examination

Additional examinations: imaging/laboratory/hystology

Symptoms

• General

– Weakness

– Loss of appetite

– Emotional lability

– Pain

• Releated to the tumor itself

– Well localised pain

– Symptoms of compression caused by tumor ( neurologic,

vascular, digestiv tract) – Bleeding

Evaluation of symptoms

Cause

Need for differential diagnosis

Importance of anamnestic data

• Family history

– Malignant disease among family members

• Data concerning lifestyle

– smoking

– Liquor consumption

– obesity

• Previous disease

– Pl: viral infection, inflammatory bowel disease, chronic pancreatic inflammation

Physical examination

• Colour of the skin: pale, icteric, cyanotic...

• Palpable tumor: abdominal, in the breast

• Digital rectal examination

• Examination of lymph node areas ( axillary, supraclavicular, inguinal.. )

Additional examinations

• Laboratory findings

• Imaging

• Endoscopy

• Biopsy ( FNB- cytologic, core biopsy-histology)

Tumor marker????

• No evidence in screening

• Importance:

– Follow up

– Effectiveness of therapy

– Differencial diagnosis

Prognostic concerns

• In which stage is diagnosed

• Histology: type, invasion, receptor status, genetic findings, molecular pathology exam.

• Resecability

• Age

• Operability

• Comorbidities

Therapeutic options

• Surgery

• Systemic treatment

• Radiotherapy

• Invasive radiological intervention ( chemo-embolisation, radiofrequency ablation…)

Therapeutic options after surgery

Wait and see

Systemic treatment

Radiotherapy

Other procedures/ second look surgery

Legislativ decree

2012/

Every cancer patient must be consulted by the onco-team before each treatment

The quideline, the recommended therapy should be the same, independently in wich center the patient is treated

Members of the team

Medical oncologist

Surgical oncologist

Radiation oncologist

If possible:

Pathologist

Radiologist

Oncology social worker and other health care team members

The onco-team function

Decision making

To give therapeutic options

Evaluate the results ( imaging, histology, new laesion, regression, progression )

Efficacy of therapy

• Progression free survival

• Overall survival

• Complet remission

• Partial remission

• Stable disease

• Progression – More than 25% , new lesion

Supportiv treatment

• What does it mean: – Treatment of side effects caused by active treatment

• Which symptoms generally appears – Vomiting, diarrhea, mucositis, hand-food syndroma,

anaemia, leucopenia, bleeding, hypertension

• What is the goal – To make possible to treat as planned : with the right dose,

in right time , in metastatic setting as long as needed

Palliative treatment

• What does it mean:

– The release of symptoms due to metastatic disease

• Symptoms

– Cahexia, anorexia, nausea,vomiting

– Dyspnoe

– Weakness(fatigue)

– Pain

– Secondary neurologic problems (polyneuropathy)

The importance of palliative treatment

• Targeting the quality of life:

– Focused on patients need and not on illness

• Helps the caregivers, the relatives

• Ensure a better compliance

Progressive loss of body weight with depletion of

both adipose tissue and skeletal muscle mass. At the time of diagnosis :between 15% and 20% In advanced disease : between 80% to 90% of patients are malnourished

Different origine: pain,malabsorbtion, depression

Characteristics: – Mostly loss of skeletal muscle mass

– Loss of appetite is present

– Complex process: role of enzymes ( cachectin), inflammatory cytokines..

Cachexia

Nausea/vomiting

Gastric outlet obstruction/intestinal obstruction Delayed gastric emptying Raised intracranial pressure :brain tumor or metastasis, Gastroesophageal reflux disease/gastritis/peptic ulcer Gross ascites Drugs : opioids,antibiotics, digoxin Metabolic disorders e.g., hypercalcemia, hyponatremia, liver failure, renal failure Psychological factors/ anxiety/anticipatory (conditioned) Chemotherapy/radiotherapy

Nausea/vomiting

• One of leading symptoms in advanced disease

• Freqvency : 40-70 %

• New drugs available:

– HT3 antagonist ( setron ) for chemotherapy induced vomiting 70-80% decrease

– For nausea less effectiv, other drugs reccomended metoclopramid , steroid, anxiolytics

Weakness (fatigue)

• Cause

– The primary tumor

– Treatment’s side effect

– Treatment induced anaemia.

– Physiological changes (cachexia, erőnlét csökkenése, cytokinek magas szintje)

– Psychosocial tényezők (anxiety, depression , insomnia)

Pain

• Importance – Connected to cancer, main cause of fear

Pain caused by: Tumor itself Treatment Pain not related to tumor

Influenced by Psychologic problems Social difficulties Cultural habits

Total pain

Characteristics of chronic pain

Start

Acut

Well defined

Chronic

uncertain

Cause Acut injury/disease Chronic prosses

Time days/weeks

Within reasonable time

month/years

illimitable

Physiologic level Sympaticotonie

„expressed suffering”

Without sings of sympathicotonie

„ looking as not suffering

Emotional level anxiety depression

Intellective level Positive meaning senseless

Behavioral level Inactivity till recover change in lifestyle/retreat

Treatment Treatment of underlying disease

Painkiller per need

Continuus, preventiv dosage

The goal of pain-killing

To provide the rest, to increase the number of sleeping hours To minimise the pain at rest Restore the patient's physical function, mental status, ability to work

Principles of pain-killing treatment

• Right time

• Right dose

• Right combination

• Individualized

• NOT AS NEEDED !!!!!

Importance of communication

• Breaking the bad news

• Therapeutic decision

• Side effects

• End of active treatment

• Difficulties in the terminal phase

Breaking bad news

First shock for the patient

How to be empathic enough, without crying with the patient

Subconcious present- patient doesn’t hear the reality: need for a relative around if it’s possible

Communication about treatment

Good patient-doctor relation

Give time for decision

Give more options

Give information about new drugs , side effects, alternativ treatments

Case of elderly patients

What age is considered old

Importance of commorbidity

Consider biological age

Importance of dose modification

Communication about end of treatment

Wait and see

Treatment holiday

Progressive disease

Best supportive care