Cancer in Relation to Pharmacy- career

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An open learning programme for pharmacistsand pharmacy technicians

Cancer: in relation topharmacy practice

Educational solutions for the NHS pharmacy workforceDLP 147


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Educational solutions for the NHS pharmacy workforce

Copyright controller HMSO 2009

An open learning programme for pharmacists

and pharmacy technicians

Cancer: in relation topharmacy practice


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ii Acknowledgements

Lead writers

Geoff Saunders, consultant pharmacist, Christie Hospital, Manchester

Jane Saunders, PCT pharmacist and community pharmacist

Joe Quinn, teacher practitioner, University of Bradford

Louise Sutton, Macmillan haemato-oncology palliative care pharmacist, Stepping Hill

Netty Wood, lead pharmacist, Essex Cancer Network

CPPE programme developers

Kuljit Thiaray, CPPE tutor

Matthew Shaw, deputy director

Project team

Paula Higginson, senior pharmacist, learning development, CPPEHazel Hughes, community pharmacist, Alliance Boots

Harlene Kithoray, CPPE tutor

Jane Lambe, community pharmacist, Co-op

Anna McNicholas, oncology pharmacist, Christie Hospital

Aamer Naeem, director, Innov8 Creative Solutions Ltd.


Jane Saunders, PCT pharmacist and community pharmacist

Louise Sutton, Macmillan haemato-oncology palliative care pharmacist, Stepping Hill

Jean Thurman, locum community pharmacist

Reviewer


This learning programme was piloted nationally by the following pharmacists and

pharmacy technicians: Antonio Cabrera, Naina Chotai, Helen Hill, Hazel Hughes,

Harlene Kithoray, Catherine Mellings, Anne Noott, Burham Zavery.

CPPE reviewer

Paula Higginson, senior pharmacist, learning development

ThanksWe would like to thank Geoff Saunders, Netty Wood and their colleagues at the

British Oncology Pharmacy Association (BOPA) for their help and guidance in

producing this open learning programme.

Production

Outset Publishing Ltd, East Sussex

Published in August 2009 by the Centre for Pharmacy Postgraduate Education,

School of Pharmacy and Pharmaceutical Sciences, University of Manchester,

Oxford Road, Manchester M13 9PT

http://www.cppe.ac.uk

Printed on FSC paper stocks using vegetable based inks.

The paper mill and printer have ISO 14001 accreditation.TT-COC-002529


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Contents

About CPPE open learning programmes vii

About this learning programme x

Supporting you, your practice and the NHS xiv

Section 1 Cancer in context 1

1.1 The structure of cancer services 3

1.2 The healthcare teams involved in cancer care 5

The cancer multidisciplinary team 5

The role of the pharmacy team 6

The role of the nursing team 7

Other professionals involved in cancer care 8

Groups who provide support to the multidisciplinary team 9

1.3 National guidance 10

1.4 An introduction to the disease 10

Staging 10

1.5 Lung cancer 11

Background 11

Incidence and mortality 12

Presentation 12Staging 13

1.6 Breast cancer 13

Background 13


Presentation 14

Staging 15

1.7 Colorectal cancer 15

Background 15


Presentation 15

Staging 15

1.8 Prostate cancer 16

Background 16


Presentation 16

Staging 17

1.9 Skin cancer 17

Background 17


Presentation 18

Staging 18

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C O N T E N T S

1.10 Cervical cancer 18

Background 18


Presentation 19

Staging 19

1.11 The impact of cancer 19

Exercises 1, 5, 6, 7, 11

Practice points 4, 9, 10, 12, 17

Summary and intended outcomes 20

Suggested answers 21

References and further reading 23

Section 2 Preventing and detecting cancer 24

2.1 Risk factors for developing cancer 24

Lifestyle 24

Genetics 26

2.2 Warning signs and symptoms in the pharmacy 28

2.3 Screening and testing 28

Genetic testing 28

Screening 29

Exercises 24, 28

Case studies 30, 32, 34

Practice points 26, 27, 29, 32, 36



References 41

Section 3 Principles of treatment 42

3.1 Aims of treatment 44

3.2 Options for treatment 46

3.3 Principles of chemotherapy 47

Combination therapy 47

Clinical trials 48

3.4 Classes of anticancer drugs 49

Alkylating agents 49

Antimetabolites 49

Mitotic inhibitors 49Cytotoxic antibiotics 49

Topoisomerase inhibitors 50

Other agents 50

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C O N T E N T S

3.5 Giving chemotherapy 51

Routes of administration 51

Administration 51

Prescribing 52

Preparation 52

Extravasation 53

3.6 Treatment monitoring 53

Case study 55

Practice points 42, 43, 46, 49, 51, 53, 57




Section 4 Responding to symptoms of disease and treatment 61

4.1 Management of side-effects of treatment 62

4.2 Infection 64

Treatment of infections 65

4.3 Nausea and vomiting 66

4.4 Gastrointestinal disturbances 69

4.5 Mucositis 70

4.6 Alopecia 70

4.7 Hand and foot syndrome (palmar plantar) 71

4.8 Tumour lysis syndrome 71

4.9 Hypersensitivity reactions 71

4.10 Managing drug interactions 71

4.11 Vitamins 72

4.12 Complementar y and alternative therapies 72

Interactions with complementary and alternative therapies 73

4.13 Safe management of symptoms 73

Enhancing pharmaceutical care 73

Exercises 61, 64, 65

Case studies 63

Practice points 65, 66, 68, 69, 72, 73, 74



References 77

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C O N T E N T S

Section 5 Supporting patients and carers 78

5.1 Communication 78

5.2 Information 81

5.3 Involving and supporting patients 83

Information sources 83

Involving the patient 83

Supporting the patient 83

5.4 Cancer survivors 84

Exercises 79, 80, 84, 85

Case study 86

Practice point 81, 82, 84, 85




Appendices

Appendix 1 Information and resources 94

Appendix 2 BOPA Competency framework for specialist 97

oncology pharmacists

Index 105

List of tables and figures

Tables

Table 1 Risk factors for breast cancer 14

Table 2 Examples of common chemotherapy regimes 48

Table 3 WHO response criteria 54

Table 4 Emetogenic potential of selected cytotoxic agents 68

and their management

Figures

Figure 1 Advice on a method for breast examination 31

Figure 2 The cell cycle 47

Figure 3 Antiemetics and their site of action 67

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About CPPE open learning programmes

About CPPE

The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the

Department of Health to provide continuing education for practising pharmacists

and pharmacy technicians providing NHS services in England. We are part of the

Workforce Academy, within the School of Pharmacy and Pharmaceutical Sciences,

which is part of the Faculty for Medical and Human Sciences.

CPPE offers a wide range of learning opportunities for the pharmacy workforce.

Our full learning portfolio is available on the internet at: http://www.cppe.ac.uk

Themes

We have allocated themes to all our learning programmes. There are 28 themes in

total and they allow you to navigate easily through our full learning portfolio. Each

theme has been assigned a different colour, and this is used to identify the theme in

the annual prospectus, inCPPE news&events, on our website, and on the covers of

all the learning programmes.

This learning programme is part of the Cancer and immunologytheme. You will

find additional learning programmes within this theme in our prospectus and on

our website.

This programme can be downloaded in PDF format from our website:

http://www.cppe.ac.uk

We recognise that people have different learning needs and not every CPPE

learning programme is suitable for every pharmacist or pharmacy technician.

Some of our programmes contain core learning, while others deliver more

complex learning that is only required to support certain roles. So we have created

three categories of learning CPPE 1 2 3 and allocated each programme to an

appropriate category.

The categories are:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialisms (CPPE may not be the provider and will

signpost you to other appropriate learning providers).

This is a learning programme.

Continuing professional development

You can use this learning programme to support your continuing professional

development (CPD). Consider what your learning needs are in this area. You may

find it useful to work with the information and activities here in a way that is

compatible with the Royal Pharmaceutical Society of Great Britains approach tocontinuing professional development (http://www.rpsgb.org.uk/registrationand

support/continuingprofessionaldevelopment) because you will be able to relate

it to your personal circumstances more closely. Use your CPD record sheets or go

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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

to: http://www.uptodate.org.uk/home/welcome.shtmlto plan and record the

actions you have taken.

Activities

Exercises

We include exercises throughout this programme as a form of self-assessment. Use

them to test your knowledge and understanding of key learning points.

Practice points

Practice points are an opportunity for you to consider your practical approach to

the effective care of patients or the provision of a service. They are discreteactivities designed to help you to identify good practice, to think through the steps

required to implement new practice, and to consider the specific needs of your

local population. Practice points are not essential learning; you must make your

own decision about whether to do them, and how long to spend on them.

The practice points in this programme have been designed to help you and your

team to make links between the learning and your daily practice and to co-ordinate

with other healthcare professionals.

Case studies

Case studies are based on actual or simulated events and are a way of

helping you to interpret protocols, deal with uncertainties and weigh up

the balance of judgments needed to arrive at a conclusion. Case studies

are designed to prepare you for similar or related cases that you may face in your

own practice.

Reflective questions

We have included reflective questions in this programme to give you an

opportunity to reflect on what you already know, or on what you have read so far,

to reinforce and extend your learning. Thinking about these questions will help

you to meet the objectives of the programme.

Linking CPPE to CPD

To help you see how our learning programme can support your CPD, look out for

this icon.

Assessment

You can complete your learning of this programme by working through the associated

assessment. This is available for you to complete and submit online through the

CPPE website: http://www.cppe.ac.uk. If you are not successful, we offer

automatic feedback after you have completed each section. We have designed the

feedback to let you know the broad area where we think you would benefit from

further learning before attempting the assessment again.

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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

References and further reading

References for all the books, articles, reports and websites mentioned in the text,together with a list of further reading to support your learning, can be found at the

end of the programme. References are indicated in the text by a superscript

number (like this3

).

Programme guardians

CPPE has adopted a quality assurance process called programme guardians.

A programme guardian is a recognised expert in an area relevant to the content of

a learning programme who will review the programme every six months. Any

corrections, additions, deletions or further supporting materials that are needed

will be posted as an update to the programme on the CPPE website. We

recommend that you refer to these updates if you are using this (or any other)

learning programme significantly after its initial publication date. A full list of

programme guardians is available on our website. You can email your comments

about this programme to them at:[email protected]

Brand names and trademarks

CPPE acknowledges the following brand names and registered trademarks which

are mentioned throughout the programme: Adcortyl in Orabase, Bonjela

,

Colpermin, Creon

, Gelclair

, NovoRapid

, Oramorph

, Ensure Plus

, Xeloda

External websites

CPPE is not responsible for the content of any non-CPPE websites mentioned in

this programme or for the accuracy of any information to be found there. The fact

that a website or organisation is mentioned in the programme does not mean that

CPPE either approves of it or endorses it.

Disclaimer

CPPE recognises that local interpretation of national guidance may differ from the

examples used in this learning programme and you are advised to check with your

own relevant local guidelines.You are also advised to use this programme with

other established reference sources. If you are reading this programme significantly

after the date of initial publication you should refer to current published evidence.

CPPE does not accept responsibility for any errors or omissions.

Feedback

We hope you find this learning programme useful for your practice. Please help us

to assess its value and effectiveness by completing the online feedback form

available on our website: http://www.cppe.ac.ukvia theMy CPPEtab. Simply

scroll down to find the learning programme title and click on the Tell us what you

thinkicon. CPPE may email you a reminder to do this. You can also email us direct

if you think your comments are urgent using the email address:[email protected]

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About this learning programme

Welcome to the CPPE open learning programme on Cancer: in relation to

pharmacy practice, which we have designed as a key element of the Cancer and

immunology theme. The aim of this programme is to give you an overview of the

most common cancers and show how the pharmacy team can help to identify and

manage them, and help to support people living with the disease.

By the time you have worked through this programme you will have extended your

knowledge about the most common cancers in the UK and improved your

confidence in dealing with this area of patient care.Your approach and

understanding should enable you to deal sensitively and effectively with people

living with cancer, and their carers.

The study time will depend on you, but we estimate that the reading and activities

will take a total of 8-10 hours.

Target audience

This programme is aimed at pharmacists and pharmacy technicians working in

any area of practice. Some sections may appear more relevant to a sector other

than the one youre working in, but we encourage you to reflect on the best way

you can apply that learning to your own sector of practice.

Learning style adopted in this programme

The programme is split into five sections:

cancer in context

preventing and detecting cancer

principles of treatment

responding to symptoms of disease and treatment

supporting patients and carers.

This programme contains enough information to provide you with an overview of

cancer and its management. However, in order to boost your understanding of the

subject we suggest that you do some further reading. We have included a list of the

references that we have used at the end of each section, many of which you may

find helpful. In addition, we recommend that you read the immunology chapter

in any anatomy and physiology textbook.

We also recommend that you visit websites set up by patient groups. Some of these

organisations have local branches. If there is one in your area then why not get in

touch with them? We have provided relevant references and web addresses where

appropriate throughout this programme, as well as information about useful

resources(see Appendix 1).

We have also included activities which ask you to plan your response to a

particular situation. These are to encourage you to reflect on your current

knowledge and understanding of the subject area, and to plan what you might say

in certain circumstances.

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Learning objectives RPSGB competences KSF dimensions

Pharmacists Pharmacy

technicians

Demonstrate an understanding of the public G1, G3, G10 TG2, TG4, TG9 Personal and people developmenthealth agenda by explaining the role of Level 1 and 2prevention, screening and risk reduction in Health, safety and security Level 1relation to your practice.

Health and well-being HWB6 Level 2

Describe the background and presentation of G1, G3 TG2, TG4 Personal and people developmentthe six most common cancers in the UK. Levels 1 and 2

Analyse your role in the management of G1, G3, G7 TG2, TG4, TG6 Personal and people developmentcancers with particular reference to appropriate Levels 1 and 2therapy, management of side-effects and Communication Level 3palliative care.

Health and well-being HWB7 Level 3

Provide appropriate advice on alternative G1, G3, G7 TG4, TG7 Personal and people developmentmethods of disease management. Level 1 and 2

Health and well-being HWB7 Level 2 andHWB10 Level 3

Develop your approach to supporting people G2, G3, G8 TG1, TG2, TG7 Communication Level 3living with cancer and their carers. Service improvement Levels 1 and 2

Information and knowledge Levels 1 and 2

Undertake a mapping exercise of local G2, G3, G8 TG1, TG2, TG7 Communication Level 3colleagues and networks to support patients.

Service improvement Levels 1 and 2Information and knowledge Levels 1 and 2

Evaluate your personal practice against your G2, G3, G8 TG1, TG2, TG7 Communication Level 3own service objectives. Service improvement Levels 1 and 2

Information and knowledge Levels 1 and 2

A B O U T T H I S L E A R N I N G P R O G R A M M E

Learning objectives

CPPE has linked all its learning programmes to the Royal Pharmaceutical Society

of Great Britains competences for pharmacists and pharmacy technicians. Thiswill make it easier for you to connect your professional practice to your learning

needs and learning activities. We have selected only the competences for general

pharmacists and pharmacy technicians, but we are aware that others exist.

We have also linked the learning to the dimensions of the NHS Knowledge and

Skills framework (KSF).

The competences and dimensions relevant to this programme are:

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Working through this programme

We would advise you to work flexibly with the materials to suit your own style of

learning. There is no right or wrong approach, but remember that the aim of yourhard work is to enable you to feel confident to meet the challenges facing you. Bear

this in mind as you work through the programme it will help you to decide if

your approach to study is working.

We have designed the programme for self-study, but as you progress through the

sections it will be essential for you to talk through some of the issues with your

staff and colleagues.

Online resources

Some of the references in this programme are to material which is only availableonline, and we assume that you have access to a computer connected to the

internet. If you do not wish to retype all the web addresses into your browser you

may find it helpful to download this programme from the CPPE website as a PDF

document containing live web links. Log on to: http://www.cppe.ac.uk

Where we think it will be helpful we have provided the URL to take you directly to

an article or specific part of a website. However, we are also aware that web links

can change (eg, the Department of Health links) so in some cases we have

provided the URL for the organisations home page only. If you have difficulty

accessing any web links, please go to the organisations home page and use

appropriate key words to search for the relevant item.

Note on NICE guidance: To find any of the NICE guidelines or technology

appraisals mentioned in this programme visit the NICE website at:

http://www.nice.org.uk On their home page, under Search NICE guidance, enter

the relevant topic and click Search.

Note on articles:If you have difficulty locating an article on the internet, search

via: http://www.google.co.ukby typing in the title, author, date and name of the

journal. It can also be helpful if you add in, at the end of the search criteria, the

website where you think the information may be, eg, dh.gov.uk

Supporting the British Oncology Pharmacy Associationcompetency framework

The British Oncology Pharmacy Association (BOPA) has developed a competency

framework to support the development and practice of pharmacy professionals

working in this specialised field. When we developed this programme, we worked

with our colleagues from the BOPA to include content, activities and assessment in

this programme that you could use to demonstrate that you are progressing

through this framework.

If you complete all of the learning and the activities in this programme then you

will be able to meet many of the competences in the foundation level of this

framework. However, you will need to undertake additional learning activities to

meet the following competences:

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Calculation of chemotherapy doses including body surface areadetermination

Able to perform dose calculations using weight or BSA

Able to use locally available BSA calculators (adult and paediatric)

Able to use calculation of carboplatin dosing using Calvert equation

Awareness of dose banding, capping and rounding doses

Procedures for safe handling of chemotherapy

Knowledge of basic safe handling procedures for pharmacy and chemotherapy

nursing staff including spillage, disposal of chemotherapeutic waste

Demonstrates basic understanding of occupational hazards of exposure to

chemotherapy drugs and waste

Understands causes of exposure to chemotherapy

Able to describe precautions when extemporaneously preparing or

manufacturing oral formulations of chemotherapy (eg, for paediatrics or clinical

trial materials)

Documentation of systemic treatment orders and delivery

Documentation of pharmaceutical care activities and outcomes, including those

specific to oncology

For more information on the BOPA competency framework, visit their website at:

http://www.bopawebsite.org and to look at the detailed competency framework

visit:

http://www.bopawebsite.org/tiki-page.php?pageName=Position+Statements

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Supporting you, your practiceand the NHS

When devising this programme we paid special attention to how it would

contribute both to your own professional development and to the overall

improvement of NHS services. We have illustrated some of these benefits in the

diagram below (you will find more detail as you progress through the

programme).

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You,your practice

and this learningprogramme

Primary care pharmacy

This programme will helpprovide the context for cancer

care as an increasing numberof patients choose home

management.

Community pharmacy

Working through theprogramme will help to focus

your development andlearning to support people

living with cancer andtheir carers.

Pharmacy technicians

The programme provides abroad introduction to the

topic of cancer care and a

framework for ongoingdevelopment.

Specialists incancer services

The programme can act as anaide memoire and tool to

help you as you support thedevelopment of others.

Secondary care pharmacy

This programme provides aframework to support your

professional development in

cancer care.


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Section 1

Cancer in context

Objectives

On completion of this section you should be able to:

describe your own developmental needs for your role in cancer care

explain about the different cancer services and the roles and

responsibilities of the healthcare professionals involved in cancer

care

discuss the national framework relating to cancer care with

particular reference to NICE guidance

state the epidemiology of cancer, listing the common signs and

symptoms of the six most common cancers in the UK

describe the background and presentation of the six most common

cancers in the UK.

This section considers cancer at a personal, local and national level. We highlight

the main policy developments that have been put in place to ensure the provision

of high quality cancer services nationwide. Then we move on to look at the

statistics relating to the common cancers in the UK, describe how they present and

how they are staged.

As with any learning programme, your key challenge is to reflect on how you

would like to change and improve your practice as a result of what you have learnt.

xercise 1 Cancer what does it mean to you?

It seems like almost everyone has been affected by cancer on a personal or social

level, whether through family members, or at work. Before you start to work

through this programme, take the time now to write down what cancer means to

you. Try to include as much detail as possible you may want to use a mind map

approach, a table, bullet points or prose.

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S E C T I O N 1

Reflection on practice

Now that you have thought through the wide range of factors that you associate

with cancer, look back through your notes. What are your learning needs in

relation to these factors? Which of your learning needs do you want to develop

first?

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C A N C E R I N C O N T E X T

Planning point

You may find it helpful to think of the areas that you find more challenging, oraspects of cancer care that make you feel uncomfortable; this can often suggest a

learning need.

List below the personal development needs that you have just identified.

You will have an opportunity to return to this exercise at the end of the

programme to evaluate your learning.

1.1 The structure of cancer services

The Calman-Hine report1

was published in 1995 as a direct result of the concerns

of government (expressed in two White Papers) and interested organisations and

individuals over the provision of cancer services. The report recommended, among

other things, that:

all patients should have access to uniformly high-quality care

services should be patient focused

there was a need for public and professional education about cancer.

In response to the reports recommendations, cancer care in the UK is now

provided throughcancer networks, developed to ensure that all patients haveaccess to specialised care. The report also introduced the concept ofcancer

units, often found in district general hospitals, where the more common cancers

are treated, and cancer centres, which provide additional expertise in common

cancers, and also manage rarer cancers after referral from cancer units.

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In response to the reports

recommendations, cancer care

in the UK is now provided

throughcancer networks,

developed to ensure that all

patients have access to

specialised care.


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S E C T I O N 1

Cancer networks consist of an overall management board, who oversee the work of

several different groups. Each group consists of a range of healthcare professionals

from different hospitals. Some groups are specific to a type of cancer (site-specific

groups), for example, lung cancer; while some groups provide support for all

appropriate patients in the network (cross-cutting groups), for example,

palliative care. Each network has a research element, as well as a user group, a

user being either an ex-patient, a patient, carer, or family member. The user group

is an important part of the cancer network, helping to ensure that the provision

and development of cancer services are patient centred.

Practice point Information toolkit

Visit: http://www.cancer.nhs.uk and locate the website of your local cancer

network.

What groups are there?

What other resources can you find?

Which of these are relevant to you?

How will you use them?

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Screening Health education

Secondary healthcareDiagnosis Staging

Treatment Follow-up

Primary healthcare, eg, GP


1.2 The healthcare teams involved in cancer care

xercise 2 A cancer care pathway

The chart below outlines the areas of healthcare that are involved at each step of

the cancer care pathway. Complete the chart by adding the titles of the key

oncology team members to each of the boxes below.

Note:You may want to consider end of life care as well.

The cancer multidisciplinary team

There are many different healthcare professionals involved in the care of the

cancer patient, from the initial GP referral through to the hospice.

Each cancer network has input from cancer centre specialists to ensure all patients

get access to appropriately specialised care. Multidisciplinary team meetings

enable specialists, for example, radiologists, surgeons, oncologists, and the patients

GP, to discuss patients who have been newly diagnosed with cancer, and agree a

management plan.

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Multidisciplinary team

meetings enable specialists, for

example, radiologists,

surgeons, oncologists, and the

patients GP, to discuss patients

who have been newly

diagnosed with cancer, and

agree a management plan.


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S E C T I O N 16

xercise 3 The multidisciplinary oncology team

Use the table below to briefly describe the roles of each member of the oncologyteam.

Clinical oncologists

Medical oncologists

Haemato-oncologists

Surgeons

Palliative careconsultants

Associate specialistsin clinical oncology

The role of the pharmacy team

Each cancer centre or unit will have a designated lead pharmacist, who has overall

responsibility for the preparation of chemotherapy. There will often be several

specialist pharmacists, especially at large centres, who will be involved in thepharmaceutical care of cancer patients. Their duties range from giving

pharmaceutical advice to other healthcare professionals, through to designing

protocols and prescribing complex medications, such as chemotherapy regimes.

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There will often be several

specialist pharmacists,

especially at large centres,

who will be involved in the

pharmaceutical care of

cancer patients.


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Cancer pharmacist:specialises in cancer care working within the

multidisciplinary team to ensure correct dosing, monitoring, and management of

side-effects and/or interactions. Cancer pharmacists are a source of advice to the

cancer team and the pharmacy department.

Aseptics pharmacy technician:specialises in aseptics they measure and dispense

chemotherapy in isolators/laminar flow cabinets.

Lead principal aseptics pharmacy technician/pharmacist:oversees aseptics

production, ensuring accurate procedures and the availability of detailed

worksheets for dispensing, and managing the unit; they also ensure all staff follow

good manufacturing practice.

Cancer network pharmacist: leads and supports the strategic direction of

chemotherapy-based cancer care within the cancer network; there is normally only

one in each cancer network.

The role of the nursing team

Specialist nurses are the backbone of the secondary care service and are often

responsible for co-ordinating cancer care. Each cancer centre or unit will have a

lead nurse with responsibility for that hospital. In addition, there will usually be

nurses who specialise in specific areas of cancer care, for example, breast, bowel or

palliative care. Any cancer unit giving chemotherapy, will be supported by a team

of nurses trained in this area, and often they will also be trained in patient

assessment.

xercise 4 Oncology nurses

Briefly describe the role of each of the nurses in the oncology team.

Nurse Role

Clinical nursespecialists

Chemotherapy nurse

Radiotherapy sister

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Any cancer unit giving

chemotherapy, will be

supported by a team of nurses

trained in this area, and often

they will also be trained in

patient assessment.


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S E C T I O N 18

Cancer researchnurse

Cancer networknurse

Palliative care nurse

Other professionals involved in cancer care include:

Oncology specialist dietitianwho provides specialised nutritional care to patients

living with cancer; both in the treatment or palliative care setting. They work in

hospitals, hospices, and in the community and are an important part of the

multidisciplinary team.

Occupational therapistwho works to increase patient safety and facilitate

independence in activities of daily living (such as dressing, bathing, feeding, and

grooming) by increasing patient strength, educating the patient and/or carer, and

arranging for additional equipment as necessary to support these everyday

activities.

Physiotherapistwho works with patients to improve their strength and functional

mobility (such as, walking, getting in and out of bed, climbing stairs) and to give

appropriate advice to the family/caregiver. A physiotherapist would assess any

equipment needs and make recommendations regarding appropriate mobility aids.

Speech therapistwho provides a variety of services for cancer patients, focusingon their communication needs, as well as any difficulty they may have with

swallowing. The speech therapist provides pre- and post-operative advice, and

assesses the patients ability to swallow and any problems they may have with their

speech, and then provides appropriate resources as required.

Each multidisciplinary team also has a co-ordinator who organises the teams

meetings for specific tumour groups. The co-ordinator is responsible for ensuring

all relevant information is available for the meeting, such as patients notes,

X-rays, CT scans.

A U G U S T 2 0 0 9


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Groups who provide support to the multidisciplinary team include:

Citizens advice bureau (CAB)

The CAB can provide advice to patients about any benefits, grants or otherassistance they may be entitled to.

Social care

Social care professionals organise a variety of services for patients who are ill and

being cared for at home, ranging from home help and meals-on-wheels, through to

financial support. Funding for these services is often an issue, but various referral

forms exist for terminally-ill patients to ensure quicker access to services. This can

be very important to patients, as many will express a wish to die at home, which

will often only be possible with extra support.

Social workersare responsible for assessing what practical and social help the

patient, or their carer, needs. They also organise and co-ordinate help from a

variety of sources.

Complementary therapists

Complementary therapy can be an important aid for patients dealing with cancer,

and there are a wide variety of complementary therapies available, such as

aromatherapy and massage. Some hospices offer complementary therapies, and

many hospices have day-care facilities where patients can attend for the day and

receive complementary therapy, in addition to participating in other activities, such

as art groups.

Practice point

Find out which complementary therapies are available to cancer patients

in your area.Try contacting your local hospice, or look on their website.

Community nurses

This broad category incorporates district nurses, who will deliver practical care,

such as changing dressings, and palliative care. It also includes specialistcommunity nurses, particularly in palliative care, who provide clinical and

educational support to fellow professionals, and support and counselling to

patients and carers. Some specialist community nurses are charitably-funded, such

as Macmillan nurses and Marie Curie nurses.

Volunteers

Volunteers help out in many different areas, from hospital visits to sitting with

dying patients. Usually volunteers are organised through charities, and are often

based at the local hospice.

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A U G U S T 2 0 0 9

Complementary therapy can be

an important aid for patients

dealing with cancer, and there

are a wide variety of

complementary therapies

available, such as

aromatherapy and massage.


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S E C T I O N 1

1.3 National guidance

One result of the Calman-Hine report was the publication of guidelines relating to

different cancers, starting with breast cancer in 1996.2

The responsibility for theseguidelines was taken over by the National Institute for Health and Clinical

Excellence (NICE) in 1999. Their guidance covers screening programmes and

diagnosis of cancer, as well as the treatment of cancer. This programme will refer

to NICE guidance, wherever appropriate.

Practice point

Look at the NICE website (http://www.nice.org.uk) Find the NICE

guidance for cancer services and if possible print a copy of the summarydocument for one or two of the cancers you wish to know more about.

1.4 An introduction to the disease

Cancer is a highly emotive word. To many people, cancer means a terrible death

sentence. As a disease, cancer covers a broad spectrum of different conditions.

There are over two hundred different types of cancer, ranging from those with

cure rates of nearly 100 percent, to those which usually result in death. Cancer is a

common disease, affecting around one in three people in their lifetime. It is among

the leading cause of death, being responsible for around one in four deaths in theUK. In addition to those affected by the disease, cancer also has an impact on

family and friends; most adults will have the experience of someone close to them

having cancer.

Cancer is defined as the disordered, abnormal, uncontrolled growth of cells. It

originates in a particular organ or tissue type, and can spread locally or can spread

to other sites in the body. The other sites are termed metastases, and a cancer

spread in this way is termed metastatic.

Cancerous changes can occur in almost any type of cell in the body, with some

types being more common than others. The four most common cancers in the UK

are lung, breast, colorectal and prostate; although the incidence of each of these

varies between men and women. Also of importance, from a public health point of

view, are malignant melanoma and cervical cancer. We will look at each of these

cancers individually in the following sections.

Although cancer can spread to other organs, we always talk of the cancer in terms

of the organ of origin, as the malignant cells from a particular organ will have

unique characteristics. These can affect which treatments work, and how the

cancer is likely to progress. For example, a breast cancer that has spread to the

lungs or bones is still referred to as breast cancer, and the treatments used will be

breast cancer treatments.

Staging

Initial assessment of the cancer will usually involve taking a scan or X-rays of the

tumour to determine the extent of the cancer. The cancer can then be staged. The

10

A U G U S T 2 0 0 9

Although cancer can spread

to other organs, we always

talk of the cancer in terms of

the organ of origin, as the

malignant cells from a

particular organ will have

unique characteristics.


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system of staging used depends on the cancer, but the TNM system is commonly

used. In this system, the T expresses tumour size, and is described as 1 to 4; the N

determines the extent of the lymph node involvement, and is expressed as 0 to 3;

and the M refers to the presence of metastases, with 0 meaning no metastases and

1 indicating the presence of metastases.

For individual cancers, the TNM system is then often converted to a different

staging system, often expressed as 0 to IV, depending on the extent of the disease.

Some cancers, for example, prostate and colorectal cancer use different systems of

staging(see later in this section).

xercise 5

What percentage of all cancer deaths do you think are attributable to lung,colorectal and breast cancer?

HINT:You can find information about this on the Cancer Research website

(http://www.cancerresearchuk.org/ ); just click on news and resources,

then cancer stats, then UK cancer incidence then the most common cancers.

Note: We have taken much of the information in this section about different

cancers from the Cancer Research UK website

(http://www.cancerresearchuk.org). The cancer statistics provided in the

remainder of Section 1 are based on information from Cancer Research UKrelating to UK data for 2005. When we developed this programme the statistics

were being updated to 2006 and we anticipate that these will now be available

on the website. It is worth checking for the most recent information.

1.5 Lung cancer

Background

Lung cancer can be divided into three main types, based on histology:

mesothelioma, small-cell lung cancer (SCLC) and non-small-cell lung cancer(NSCLC). Generally, the SCLC variant has a better initial response to treatment,

but returns rapidly, and is often associated with a worse outcome. Around 90

percent of lung cancer is associated with smoking.3

Lung cancer was rare up until

E

11

A U G U S T 2 0 0 9

For individual cancers,

the TNM system is then often

converted to a different staging

system, often expressed as

0 to IV, depending on the

extent of the disease.


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S E C T I O N 1

the early years of the twentieth century, when the impact of the wider availability

of mass-produced, cheap cigarettes was felt. Other possible causes of lung cancer

include asbestos exposure and radon gas exposure.

Incidence and mortality

Lung cancer is the second most common cancer in men and the third most

common in women. There were 38,598 cases of lung cancer registered in 2005,

with 80 percent occurring in patients over the age of 60.3

However, the incidence

is currently dropping in men, but is stable in women.3

Overall, one year after diagnosis, around 25 percent of patients will still be alive,

and the five-year survival rate is seven percent, but much depends on the stage the

cancer had reached when diagnosed earlier diagnosis leads to improved survival.

Presentation

The classic presentation involves some or all of the following symptoms:

haemoptysis

cough

dyspnoea

chest discomfort

recurrent / persistent chest infections.

Non-specific symptoms may also be present, such as weight loss, anorexia and/or

fatigue.

Practice point

Consider the symptoms of lung cancer.Why do you think many patients do

not present until the disease is advanced? Jot down the steps that you could

take to improve this.

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Planning point

Which of these can you commit to?

With larger, locally-advanced tumours, further symptoms may be present,

including:

superior vena cava obstruction:

facial swelling

dilated veins on the upper chest, shoulders, arms

hoarseness

oesophageal symptoms:

dysphagia

pleural effusions.

A minority of patients may present with paraneoplastic syndrome, especiallypatients with SCLC. Features of this include raised calcium levels, syndrome of

inappropriate diuretic hormone secretion (SIADH) and potentially increased

blood clotting (hypercoaguability).

Initial investigation for a suspected lung cancer is sputum cytology, to detect the

presence of malignant cells in the sputum. In addition, a chest X-ray will usually

reveal a mass. A positive result on both of these is usually followed up by a

bronchoscopy; a long, flexible camera passed into the lungs. Ideally a biopsy of any

mass found will be taken, to determine the histology of the cancer.

Staging

The extent of the cancer is usually expressed as stage IA to IV. Stage I tumours are

small, and can often be treated surgically, with a good survival rate. Stage IV

tumours show metastatic spread, and can only be controlled. Unfortunately, many

patients do not present until they have advanced disease.

1.6 Breast cancer

Background

Breast cancers are differentiated into special types or no special type, based on

histological appearance. An important histological investigation for breast cancer is

to determine the estrogen-receptor (ER) status and the HER2-receptor status, as

these can influence treatment options.

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A U G U S T 2 0 0 9

Initial investigation for a

suspected lung cancer is

sputum cytology, to detect the

presence of malignant cells in

the sputum.


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S E C T I O N 114

The main risk factor for breast cancer is increasing age; however, it has been

shown that a first pregnancy after 32 years of age, no pregnancy, late menopause

and early menarche can affect the chance of developing breast cancer. There are

several other risk factors, as shown in Table 1.

TABLE 1 Risk factors for breast cancer

Risk factor

Increasing age Greatest risk

Family history

Geographical location

Non-cancerous breast disease (atypical ductal hyperplasia)

Exposure to radiation

First birth at 32 years or more

No pregnancy

Obesity

Late age of menopause

Early age of first period Lower risk

Source: adapted from Spence RAJ, Johnston PG. Oncology. Oxford: Oxford University Press, 2001.


Breast cancer is the most common cancer in women (45,500 new cases diagnosed

in 2005). Male breast cancer is rare, but not unknown (300 cases in 20053

). The

incidence of breast cancer has been steadily rising for the past 25 years. However,

it is worth noting that cure rates have also risen. Around 60 percent of cases occur

in patients over 60.

In 2009, the quoted five-year survival rate is 80 percent, although this depends on

age and the staging of the cancer at initial diagnosis. Those diagnosed at stage I

have a five-year survival rate of nearly 88 percent, compared with around10 percent in patients diagnosed at stage IV. The best five-year survival is shown in

patients between 50 and 69; younger and older patients tend to do worse.

Presentation

Breast cancer usually presents with the patient finding one of the following:

a lump in their breast

breast pain

discharge from the nipple.

Although any one of these needs further investigation, by themselves they dontnecessarily mean that the woman has cancer.

There are rarely any other symptoms of breast cancer, unless the disease is

advanced. If it is advanced the patient may report symptoms from the metastases

A U G U S T 2 0 0 9

The incidence of breast cancer

has been steadily rising for the

past 25 years. However, it is

worth noting that cure rates

have also risen.


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(eg, abdominal pain from liver metastases). Investigation will involve a biopsy of

the suspected tumour. Usually this is a fine-needle aspiration, which can produce a

result within 30 minutes. This result can be definitive, but in some cases a larger

core biopsy, or even an open biopsy, involving surgery, may be needed.

Staging

Breast cancer is staged as between 0 and IV, with 0 being a locally-confined

tumour (often described as a carcinoma in situ) and IV being metastatic disease.

1.7 Colorectal cancer

Background

Colorectal cancer refers to tumours of the large bowel, including the rectum.Generally colorectal cancers are of the same type -adenocarcinoma.

The main risk factors for colorectal cancer are a family history of colorectal cancer,

dietary factors and other colorectal disease (such as ulcerative colitis).


Colorectal cancer is the third most common cancer in men and the second most

common in women, with 36,500 cases in 2005. Around 75 percent of new cases

occur in patients over 65 years of age.3

The incidence of colorectal cancer has

remained steady for the past 10 years, although the cure rate has improved.

Five-year survival is around 52 percent. As with other cancers this varies with age

and the stage of the disease. Dukes stage A at diagnosis gives a five-year survival

rate of 83 percent, but this drops to just three percent for those with stage D

disease.

Presentation

Colorectal cancer typically presents with abdominal pain, a change in bowel habit,

rectal bleeding or iron-deficiency anaemia. A minority of patients will present with

bowel obstruction, particularly those where the left side of the bowel is affected.

Patients will often have a palpable mass present.

Screening for colorectal cancer can be done using a faecal occult blood test, to

detect the presence of blood in the stool. This will not usually be due to cancer, as

other conditions such as polyps can cause this; however, it is a valuable method to

identify patients who require further investigation.

Staging

Traditionally colorectal cancer has been staged based on the Dukes system, with A

being a locally-confined tumour and D being metastatic spread. The system has

been modified over time, and may be amended to the TNM system for staging.

15

A U G U S T 2 0 0 9

The incidence of colorectal

cancer has remained steady for

the past 10 years, although the

cure rate has improved.

Screening for colorectal cancer

can be done using a faecal

occult blood test, to detect the

presence of blood in the stool.


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S E C T I O N 1

1.8 Prostate cancer

Background

The prostate gland is found only in men, located just below the bladder and next

to the rectum. Prostate cancers are usually adenocarcinomas.

Risk factors for prostate cancer include diet, environmental factors and genetic

background, such as family history and ethnicity. Prostate cancer is more common

in men from a Black Caribbean, Black African and mixed race background. Indian

and Pakistani men have a greater risk than Caucasian men; men from a Chinese or

Bangladeshi background are less at risk. However, the main risk factor is increasing

age.


Prostate cancer is the most common cancer in men, with 34,000 cases in 2005.3

The disease has increased steadily in incidence but not in mortality; probably due

to improved screening procedures and methods. Around 60 percent of cases occur

in patients over 70, and it is extremely rare in the under-50s.

The five-year survival rate is currently around 70 percent. It has been found that

around 80 percent of 80-year-old men have evidence of malignant changes in the

prostate at autopsy, without any obvious disease. A diagnosis of prostate cancer in

an older patient doesnt need to be considered a death sentence if not treated. Men

are found to have prostate cancer at post-mortem without it being the cause of

death. On some occasions there is a real challenge in deciding whether to treat

prostate cancer or not as the effects of treatment may be worse than the cancer itself.

Presentation

Initial symptoms of prostate cancer are:

hesitancy in passing urine

increased frequency

increased urgency

having to get up in the night to urinate.

However, these symptoms are the same as those of non-cancerous enlargement ofthe prostate. Consequently, many cancers are found by chance, following an

operation to reduce the size of the gland. Symptoms of more advanced disease

include:

impotence

incontinence

localised pain

bone pain can also occur if metastases are present.

Initial investigation would usually involve the doctor feeling the prostate gland

manually, via the rectum. Biopsies of the prostate are usually taken. More accurate

staging of the disease is carried out by transrectal ultrasound. Prostate specific

antigen (PSA) is usually measured, however this tends to be more useful in

monitoring the disease than diagnosing it.

16

A U G U S T 2 0 0 9

Prostate cancer has increased

steadily in incidence but not in

mortality; probably due to

improved screening procedures

and methods.

During initial investigation for

prostate cancer, specific

antigen (PSA) is usually

measured, however this tends

to be more useful in

monitoring the disease than

diagnosing it.


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Screening programmes for prostate cancer using PSA levels are controversial, as a

significant minority of men with cancer will have a normal PSA, while some with

an elevated PSA will not have cancer and may undergo biopsy for no reason.

Clinical trials are presently being carried out to determine if there is any value in a

screening programme.

Staging

Prostate cancer is usually staged using the Gleason score, ranging from two being

the least aggressive cancer to 10 being the most aggressive.

Practice point:Plan your response

A regular patient has just found out that his father is undergoing tests, to

rule out prostate cancer. He is angry and upset as he was not allowed time

off work to attend the appointments with his father. His father, due to stress

and anxiety, has been unable to retain any of the information provided by

the hospital. He simply wants to know, if it is identified as cancer does it

mean that his father will be terminally ill?

How would you respond?

1.9 Skin cancer

Background

Skin cancers can be divided into two main types melanoma and non-melanoma.

The non-melanoma cancers are the most common cancer in the UK, but are

usually disregarded in league tables as they are so easily treated. In this section we

will just look at melanoma.

A melanoma is a cancer of the melanocytes, skin cells designed to protect the

body from excessive ultra-violet (UV) light. These cells darken on exposure to UV

light, giving rise to the characteristic sun-tan. The main risk factors for melanoma

are skin type and exposure to UV light, particularly at a young age. The fairer a

persons skin and the more easily it burns in the sun, the greater the risk of

melanoma. A family history of melanoma also increases the risk of developing the

disease.


Malignant melanoma accounted for 9,500 registered cases in 2005,3 32 percent of

these in patients under the age of 50. It is rapidly increasing in incidence, and is

now the most common cancer in patients in the 15-34 age group.

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A U G U S T 2 0 0 9

The main risk factors for

melanoma are skin type and

exposure to UV light,

particularly at a young age.

A family history of melanoma

also increases the risk of

developing the disease.


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S E C T I O N 1

The five-year survival rate is currently 78 percent in men and 91 percent in

women. Improved survival is linked with a thinner tumour on diagnosis, which is

linked with earlier presentation.

Presentation

Melanoma presents as a dark raised lesion on the skin, usually on the trunk in

males and the lower extremities in females. Symptoms are rare with early stage

disease, and diagnosis is based on examination, using the ABCD criteria:

A Asymmetry of shape

B Border notching (irregular border)

C Colour darkening

D Diameter enlargement (usually around 7-9 mm)

A biopsy would be taken of any suspicious lesion, to confirm the presence of

cancerous changes.

There are no screening programmes for melanoma at present, but there are public

education initiatives to encourage awareness about sun protection.

Staging

Melanoma is staged from 1A to IV, depending on the thickness of the tumour and

any local or metastatic spread.

1.10 Cervical cancer

Background

Cervical cancer can consist of a wide range of different histological presentations,

from squamous cell carcinoma (about 66 percent) to more unusual variants.

The cause of cervical cancer appears to be infection with certain types of human

papillomavirus (HPV). Research has shown that the risk of developing cervical

cancer is linked to the length of exposure to the virus. According to CancerHelp UK

(http://www.cancerhelp.org.uk ) groups at increased risk include women with an

early age of first intercourse (16 years or less) and cigarette smokers.

Recently the development of a vaccine against HPV has raised hopes of drastically

reducing or eradicating cervical cancer.


Invasive cervical cancer affected 2,803 patients in the UK in 2005, occurring in an

even spread in women over the age of 25.3

The incidence of cervical cancer is

decreasing, which probably represents the impact of screening programmes.

Worldwide however, cervical cancer is the second most common cancer, with

80 percent of cases occurring in developing nations.

The five-year survival rate in the UK is around 68 percent, affected very much by

age at diagnosis. In the 15-39 age group the five-year survival rate is 83 percent,

while this drops to 22 percent in the 80-99 age group.4

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A U G U S T 2 0 0 9

There are no screening

programmes for melanoma at

present, but there are public

education initiatives to

encourage awareness about

sun protection.

The cause of cervical cancer

appears to be infection with

certain types of human

papillomavirus. Research has

shown that the risk of

developing cervical cancer is

linked to the length of exposure

to the virus.


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Presentation

Early-stage disease is usually asymptomatic, and detected on a cervical smear.

Symptoms of later stage disease can include:

vaginal bleeding

foul smelling vaginal discharge

pain (occasionally backache).

Investigation consists of colposcopy (viewing of the cervix and vagina through a

magnifying instrument), usually followed by a biopsy of any visible lesions.

Staging

It is staged from 0 (carcinomain situ) through to IVB (tumour with distant

metastases).

1.11 The impact of cancer

Being diagnosed with cancer is a major psychological shock. Most people will not

understand the difference between the types or stages of cancer, and therefore

assume that a diagnosis of cancer is a death sentence. Cancer will also have an

impact on the family and friends of the patient.

Cancer patients may require extra care; they may have symptoms caused by the

disease itself, or by the treatment given. There is also the anxiety of waiting for

results, to see if the disease has worsened or improved. As you work through the

rest of this programme try to reflect on the patients perspective as well as your

own. Symptoms you may consider unimportant may be devastating to the patient,

and the burden of repeated hospital attendances and financial worries can be

draining. Contrastingly, things that you think are essential may not seem relevant

to your patients.

Any plans for giving or monitoring cancer treatments need to focus on the patient

as an individual. Remember we are never treating a type of cancer, we are treating

apatientwith a type of cancer.

19

A U G U S T 2 0 0 9

As you work through the rest of

this programme try to reflect

on the patients perspective as

well as your own.

Remember we are never

treating a type of cancer, we

are treating apatientwith a

type of cancer.


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Learning objective Well can you?

Describe your own developmental needs for yourrole in cancer care.

Explain about the different cancer services and theroles and responsibilities of the healthcareprofessionals involved in cancer care.

Discuss the national framework relating to cancercare with particular reference to NICE guidance.

State the epidemiology of cancer, listing thecommon signs and symptoms of the six mostcommon cancers in the UK.

Describe the background and presentation of thesix most common cancers in the UK.

S E C T I O N 120

Summary

In this section you have considered what you need to learn about cancer and

started to plan how you will do this. We have discussed how cancer services are

organised, looked at some of the organisations involved in cancer and highlighted

six of the most common cancers.

Intended outcomes

Having worked through this section you should be able to:

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Suggested answers

Exercise 3 The multidisciplinary oncology team (page 6)

Clinical oncologistshave undergone specialist training in the provision of

radiotherapy and chemotherapy and are members of the Royal College of

Radiologists (oncology section). They provide non-surgical, (ie, radiotherapy and

chemotherapy) advice.

Medical oncologistshave undergone specialist training in the management of

malignancies using chemotherapy and are members of the Royal College of

Physicians. They provide chemotherapy advice.

Haemato-oncologistshave undergone specialist training in haematology and the

management of haematological malignancies and are members of both the RoyalCollege of Physicians and Royal College of Pathologists. They provide medical advice.

Surgeonsprovide the multidisciplinary team with surgical advice on the

management of the cancer patient and are members of the Royal College of

Surgeons.

Palliative care consultantshave had specialist training in palliative care (the

holistic care of patients with advanced progressive illness) and are members of the

Royal College of Physicians.

Associate specialists in clinical oncologysupport consultants, and supervise junior

doctors and medical students during their oncology postings.

Exercise 4 Oncology nurses (page 7)

Theclinical nurse specialistspecialises in one tumour area (such as lymphoma or

lung cancer) and acts as a key worker linking the patient with the multidisciplinary

team throughout the whole patient pathway. They are a resource for patients,

relatives, and colleagues, to ensure that the cancer patient is given the highest

standard of care possible.

Thechemotherapy nurseadministers the chemotherapy to the patient. They also

provide a point of advice for patients during treatment.

Theradiotherapy sisteruses their specialist knowledge and skills in the

identification, assessment, and management of radiotherapy-induced side-effects.

They provide emotional and psychological support and symptom control for patients

during a course of radiotherapy or chemo/radiation. In some hospitals they will also

provide support after treatment in nurse-led clinics.

Thecancer research nursespecialises in cancer clinical trials, carrying out all

essential trial activities, from setting up the trial to advising the multidisciplinary

team on treatment protocols.

Thecancer network nurseleads the strategic direction of cancer care within the

network; there is normally only one per cancer network.

Thepalliative care nursespecialises in the palliative care of patients, including non-

cancer patients and is part of the palliative care team.

A

A

21

A U G U S T 2 0 0 9


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S E C T I O N 122

Exercise 5 (page 11)

What percentage of all cancer deaths do you think are attributable to lung,

colorectal and breast cancer?

In 2005 in the UK, one in four (24 percent) of all cancer deaths were from lung

cancer. Colorectal cancer was the second most common cause of cancer death

(10 percent) and breast cancer was the third most common cause of cancer death in

all persons (8 percent).3

A

A U G U S T 2 0 0 9


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References and further reading

References1. Calman K, Hine D. A policy framework for commissioning cancer services. London:

Department of Health, 1995.

2. Department of Health. Improving outcomes in breast cancer.London: DH, 1996.

Updated version only now available NICE (2002) Guidance on cancer services:

improving outcomes in breast cancer Manual update. Available online at:

http://www.nice.org

3. Cancer Research UK, CancerStats. Available only online at:

http://info.cancerresearchuk.org/cancerstats/(accessed 10 August 2009).

Further reading

Ballinger AB, Anggiansah C. Colorectal cancer.British Medical Journal, 2007; 335:

715-8.

Damber J, Aus G. Prostate cancer. Lancet, 2008; 371: 1710-21.

Department of Health. The NHS cancer plan: a plan for investment, a plan for

reform. London: Department of Health, 2000. Available online at:

http://www.dh.gov.uk

Department of Health. The cancer reform strategy. London: Department of Health,

2007. Available online at:http://www.dh.gov.uk

Office for National Statistics. Mortality statistics: cause. England &Wales, 2006. vol.

DH2 No.32. London:TSO, 2006. Available online at:

http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=618

General Register Office for Scotland. Scotlands Population 2006 The Registrar

Generals annual review of demographic trends. Edinburgh, GROS, 2006.

Available online at: http://www.gro-scotland.gov.uk/statistics/publications-

and-data/annual-report-publications/rgs-annual-review-2006/index.html

Northern Ireland Cancer Registry. Cancer mortality in Northern Ireland.

Online statistics available at:

http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/#d.en.26094

Spence RAJ, Johnston PG. Oncology. Oxford: Oxford University Press, 2001.

Thompson JF, Scoyler RA, Kefford RF. Cutaneous melanoma. Lancet, 2005; 365:

687-701.

Veronesi U, Boyle P, Goldhirsch A, Orecchia R,Viale G. Breast cancer. Lancet,

2005; 365: 1727-41.

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http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/#d.en.26094http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/#d.en.26094http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/#d.en.26094


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Section 2

Preventing and detecting cancer

Objectives

On completion of this section you should be able to:

explain the role of the pharmacy team in advising people on

approaches they can take to reduce their personal risk of developing

cancer

recognise common signs and symptoms that customers may present

with in the pharmacy

describe the most commonly-used screening methods

identify the points at which referral should be made to an

appropriate healthcare professional

raise awareness of risk factors and the steps that can be taken by the

wider population in avoiding these.

Cancer is a prominent health issue. Many people are concerned about developing

the disease. Cancer may therefore become a topic of discussion between yourself

and patients. These discussions give you a valuable opportunity to provide

reassurance and information about the various ways that people can reduce their

risk of cancer or ensure early detection.

2.1 Risk factors for developing cancer

Lifestyle

There are several ways that people can adapt their lifestyle to reduce the risk of

developing certain cancers. Pharmacists and the pharmacy support team are well

placed to raise awareness of these lifestyle issues and to help their customers make

changes which may lower their risks of developing the disease.

xercise 6

Complete the table over the page, outlining the reason why you think the lifestyle

may be considered to be a risk factor for developing cancer, and then suggest what

you can do to help customers reduce these risks. We have completed the first line

as an example.

E

24

A U G U S T 2 0 0 9

Pharmacists and the pharmacy

support team are well placed

to raise awareness of lifestyle

issues and to help their

customers make changes

which may lower their risks

of developing the disease.


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P R E V E N T I N G A N D D E T E C T I N G C A N C E R

Having worked through this exercise you may feel there are areas where you need

to know more. Reflect on your learning needs and visit the CPPE website

(http://www.cppe.ac.uk ) for details of relevant open learning programmes

including:Stop smoking, Nutrition,Weight management, and Sexual health: testing and

treating.

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A U G U S T 2 0 0 9

Lifestyle factor Why is it a risk factor for What can you do in thedeveloping cancer? pharmacy?

Smoking Cigarette smoking is responsible for at Pharmacists are able to advise on

least one third of all cancer deaths in the nicotine replacement therapies and

UK. This includes not only lung cancers, in some cases supply these free of charge

but also cancers of the mouth, larynx, under a patient group direction.

oesophagus, pancreas, cervix and bladder.

Sunbathing

Diet

Being overweight

Occupational factors

Drugs

Infectious agents


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S E C T I O N 2

Genetics

As well as these modifiable risk factors, people may be concerned that they are at

an increased risk of developing cancer because of their genes. Research is

underway to clarify the links between genetics and cancer and also to see if future

treatments can be tailored specifically to individuals.1

You may find it useful to

scan through current newspapers and magazines to see what messages your

customers are getting about genetics, cancer risk and therapies.

Practice point:Plan your response

A patient is concerned that they may be at risk of developing cancer, as a

family member has recently been diagnosed.

What factors do you need to take into account?

How would you respond?

Inheritable cancers are relatively rare, so it is important to reassure patients when

they are concerned. When considering genetic risk, three generations of family

should be considered rather than just immediate family. The patient needs to list all

the well relatives, as well as those that have been affected by cancer.

Reflective question:Knowledge check

Write down an example of a first degree relative and a second degree relative.

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A U G U S T 2 0 0 9

Research is underway to clarifythe links between genetics and

cancer and also to see if future

treatments can be tailored

specifically to individuals.


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Which genes increase the risk of developing cancer?

A number of genes have been identified that increase the risk of the patient

developing cancer. These genes are thought to be responsible for approximately

five to ten percent of the most common cancers, such as breast and colorectal.2

These genes are called high penetrance genes as they commonly cause clinical

manifestations. Examples are BRCA1 and BRCA2. There are also low penetrance

genes that are less likely to cause such manifestations. Examples include CHEK2

and PALB2.3

The remaining 90-95 percent of cancers are thought to occur due to

a combination of weak genetic factors and non-genetic factors.

The genes implicated in causing cancer are mutated human genes. They would

normally be involved in cellular functions within the cell cycle. The mutation

results in disruption to the normal processes and an increased risk of the cells

becoming cancerous.

These high risk genes are associated with causing cancers in specific organs by

increasing the risk of the cells becoming cancerous; they do not put the patient at

greater risk of developing cancer in general. Some patients in possession of these

genes will live healthy lives. For example, the BRCA1 and BRCA2 genes are

responsible for less than 10 percent of all breast cancers. However, patients with

these genes will have a higher risk of developing breast or ovarian cancer compared

with patients without the genes. The average risk for developing breast cancer for a

woman is 11 percent, and for women who carry these genes it is 85 percent.4

There are several other genetic syndromes. However, the main features that may

suggest inherited cancer susceptibility in a family and necessitate a referral to the

GP include:

several close (first or second degree) relatives with the same cancer, an

associated cancer (eg, breast or ovary) or a rare cancer (eg, retinoblastoma)

multiple cancers in paired organs (eg, bilateral breast and ovarian cancer)

multiple tumours in different organ systems in one individual

diagnosis at an early age (eg, colon cancer in the 20s and breast cancer before

the age of 40).

Practice pointWhere might you research further for information about genetic cancer

links? Identify at least two websites that you could use.

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A U G U S T 2 0 0 9

Patients with the BRCA1 and

BRCA2 genes will have a higher

risk of developing breast or

ovarian cancer compared with

patients without the genes.


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S E C T I O N 2

2.2 Warning signs and symptoms in the pharmacy

Many cancers can be successfully treated if detected early enough. It is therefore

important to encourage people to see their GP if they have any symptoms thatcould indicate cancer. Because there are so many types of cancer affecting

different organs in the body, a variety of signs and symptoms can develop, so

anything unusual for that particular patient should be reported as soon as possible.

xercise 7

List the symptoms that you think might potentially indicate cancer and require

further investigation and state which cancers they may be related to.

Turn to the end of the section for suggested answers.

2.3 Screening and testing

Genetic testing

Genetic testing is controversial. If someone is considering genetic testing they will

need in-depth counselling, with plenty of time for reflection both before and after

the genetic testing, to allow them to reach a well-informed opinion. This type of

testing is effectively a two-stage process. The first step is to identify the faulty gene

in the family. The second step is to offer testing to individuals in the family once

the gene has been identified. It is only carried out by recognised laboratories and is

backed up by formal counselling and support.

A negative result could engender false hope and a positive result could create

enormous anxiety. In the case of breast cancer there is presently insufficient

information available on which to base a decision should the incriminating genes

be detected.

A

E

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A U G U S T 2 0 0 9

It is important to encourage

people to see their GP if they

have any symptoms that could

indicate cancer.

If someone is considering

genetic testing they will need

in-depth counselling, with

plenty of time for reflection

both before and after the

genetic testing, to allow them

to reach a well-informed

opinion.


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A positive result may also lead to the decision to undergo prophylactic mastectomy

or oophorectomy, in the hope that it will save life. Information on the benefits of

such surgery is limited. A Cochrane database review found that although

prophylactic mastectomy reduced the incidence of and death from breast cancer,

there was insufficient evidence that it improved survival. Women who chose to

follow this route were satisfied with their decision, but were less satisfied with the

cosmetic result and their body image.5

Genetic testing is available at most specialist cancer centres and patients would

usually be referred by their GP or specialist consultant. Initially the geneticist will

look at the patients family tree in detail. They will then decide if genetic testing is

appropriate and which family members should be tested.

Screening

Screening does not reduce the risk of developing cancer, but for some cancers it

may help with early detection and hence improve the therapeutic outcome and

increase survival. Screening should be distinguished from diagnosis. The aim of

screening is to look for the presence or absence of a disorder in an otherwise

healthy person, while diagnosis involves identifying a disease or condition in a

patient who has existing signs and symptoms. Moreover, screening often involves

just one or two tests, while diagnosis can often involve a wide range of questions

and examinations.

Practice points

Visit the CancerHelp website: http://www.cancerhelp.org.uk/ (select

bowel cancer, then diagnosing, then tests). Familiarise yourself with

the tests; you may wish to repeat this exercise for other cancers.

Visit the Department of Health website:

http://www.cancerscreening.nhs.uk/index.htmland view the

information provided on the national screening programmes.

The value of screening for particular cancers depends on several factors:

how well tests distinguish between those individuals with cancer and those

without

to what extent any diagnosed malignancy causes clinical problems

what the beneficial and harmful effects of the treatment are on the patients

quality of life.

Screening is only of value if the patient can be offered effective treatment. Unlike

diagnosis, screening for cancer is still in its infancy, with tests currently available

for breast, cervical and bowel cancers. However, not all the tests are highly

sensitive. For example, prostate specific antigen does not necessarily screen forprostate cancer. For more information about specificity and sensitivity have a look

at the CPPE open learning programme,Screening populations, monitoring people,

examining patients, and in particular Booklet 2.

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A U G U S T 2 0 0 9

A Cochrane database review

found that although

prophylactic mastectomy

reduced the incidence of and

death from breast cancer,

there was insufficient evidence

that it improved survival.

Unlike diagnosis, screening

for cancer is still in its infancy,

with tests currently available

for breast, cervical and

bowel cancers.


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S E C T I O N 2

Lung cancer screening

There is currently no evidence that screening is effective in reducing the risk of

lung cancer mortality.

Vera Butlin

Vera Butlin is 76 years old and has been a smoker (more than 40 a

day) for most of her life. Vera would like some advice on her cough,

aches and pains. She says that she has had a cough for years but

recently it is much worse and keeps her awake all night.

What advice would you offer her?

Turn to the end of the section for suggested answers.

Breast cancer screening


What is the difference between breast awareness and breast self-examination?

Breast self-examination is important (see Figure 1 below), but breast awareness is

considered to be even more important.6, 7

This means being familiar with how the

breasts feel and look, as well as the changes that occur each month. Putting too

much emphas

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