CLINICAL LESSON No. 1
(Practical – 6 hours)
Themes:
EPIDEMIOLOGY OF MALIGNANT DISEASES.
PRINCIPLES OF ONCOLOGICAL CARE. METHODS OF DIAGNOSTICS AND PROPHYLAXES OF CANCERS. TNM CLASSIFICATION.
PRINCIPLES OF TREATMENT AND FOLLOW-UP OF CANCER PATIENTS.
Aim: to teach students
♦to take and describe the patient’s history, habits, (cigarette smoking, alcohol consumption), occupational factors (toxic substances, sun and wind, and other environmental exposure), predisposing factors and diseases that have had patients;
♦to be able to perform the physical examination of patient;
♦to know the main diagnostic procedures, staging, and classifications.
Professional motivation:
Knowledge of the etiology, predisposing factors, clinical signs and symptoms of early forms the most common of malignant tumors will help students to be “oncological alert” and be able to help patients with emerging problems.
In Ukraine (2012) there were diagnosed 162,541 (357.6 per 100,000) new cases of all forms of malignancy. Of these, the highest incidence rates were in Sevastopol (450.5), Kirovograd (380.0) regions and Republic of Crimea (373.6). A high incidence rates were noticed in Mykolaiv (373.7), Zaporizhzhya (365.0), and Dnipropetrovsk (356.1) regions. The incidence rates were rather low in Zakarpattya (236.2), Lutsk(258.4), Rivne (264.7), Ivano-Frankivsk (277.1), Lviv (287.7) and Ternopil (294.1) regions. The top five sites were occupied by the following tumours in men: lung cancer (21.2%), cancer of the stomach (10.6%), skin cancers (10.0%), prostate cancer (6.5%), and rectum (5.7%); in women: breast cancer (18.9%), skin cancers (13.4%), cancer of the uterine body (8.0%), cancer of the stomach (6.9%), and cancer of the uterine cervix (6.2%). It is necessary to underline that there is constant growth of both the incidence and mortality rates of cancer. The incidence rates have been increasing by 2.5 % annually for the past same decades. In 2020, it is estimated, that there will be about 200,000 new cases (~ 400.0 per 100,000) in Ukraine.
Key words and phrases: epidemiology, etiology, incidence/mortality rates, survival, cigarette smoking, alcohol consumption, ionizing/solar ultraviolet radiation, asbestos, dietary habits, diagnosis, histopathology, biopsy, tumor markers, genetic, oncofetal proteins (α-Fetoprotein), cancer antigen (Carcinoembryonic antigen, CEA)), hormones, staging, prevention, early detection.
Work out of practical tasks.
In the Outpatient Department of Oncological Hospital student should learn the standards of diagnosis of malignant diseases and how to fill in statistical documents for primary cancer patients.
In the Department of Cancer Control and Statistics student should learn basics of cancer registry and main statistical data (incidence and mortality rate, etc.).
Student’s self-learning programme:
I. Epidemiology and etiology
A. Cancer epidemiology. Epidemiology is the study and comparison of the incidence of cancer in various populations or over time. Differences or changes in cancer incidence are used to define groups at increased or decreased risk and to examine risk factors that might be responsible for these differences or changes.
Incidence and mortality rates
a. Incidence refers to the overall number of people developing cancer in a particular time frame, usually 1 year;
b. Incidence rate is the number of new cases of cancers per 100,000 populations per year. Incidence rates provide an estimate that a particular individual will develop cancer in a given time frame;
c. Mortality rate refers to the number of people dying from cancer per 100,000 populations per year;
d. Case fatality rate is the percentage of people with a particular cancer who die from that cancer;
e. Prevalence is the percentage of a population that is affected with cancer at a specific point at a given time.
Survival. The overall 5-year survival rate for all cancers has improved from about 10 % in 1960 to about 50 % in 1990. Most of the treatment-related improvement in survival has occurred as the result of early detection of common cancers; it is not yet clear whether some of these early cancers have the same lethal biologic potential as cancers discovered in a more advanced state. Early detection and diagnosis of cancers that appear histologically identical but are biologically less lethal can yield misleading survival figures.
B. Etiology. At least 80 % of cancers in Americans are caused by living habits (smoking, alcohol consumption, and diet) and environmental carcinogens.
1. Tobacco.
2. Alcohol.
3. Ionizing radiation.
4. Environmental exposure: asbestos-related cancers; solar ultraviolet radiation (UV-B); electromagnetic fields.
5. Dietary habits, body habits, and cancer risk
6. Chemical and microbial agents and genetic risk factors
7. Oncogenes and viruses.
II. Principles of cancer diagnosis using laboratory tests
A. Histopathology (tumor biopsy);
B. Tumor markers
1. Types of tumor markers:
a. Cell surface markers;
b. Genetic markers;
c. Tumor markers found in the blood or other body fluids.
2. Oncofetal proteins:
a. α-Fetoprotein (α-FP);
b. Carcinoembryonic antigen (CEA)
3. Hormones:
a. Human chorionic gonadotropin (β-HCG);
b. Thyrocalcitonin.
4. Enzymes:
a. Prostate-specific antigen (PSA);
b. Prostatic acid phosphatase;
c. Lactic dehydrogenase (LDH);
d. Neuron-specific enolase (NSE).
5. Cancer antigens (CAs):
a. CA125;
b. CA 15-3;
c. CA 19-9.
III. Staging
Principles of cancer staging
1. Determining the extent of disease
2. Staging should describe both the tumor and the host
TNM staging systems (TNM Classification of Malignant Tumours, 2002). Many tumors are associated with several staging systems, which are in continuous evolution. Readers should consult an up-to-date staging manual because of the frequent revisions.
IV. Prevention and early detection
A. Prevention
Lifestyle Recommendations:
1. Don’t use tobacco in any form: smoking, chewing, or snuff dipping.
2. Adjust total fat intake to 20% or less of calories, and opt for lipids with less risk for heart disease or cancer, such as monounsaturated oils. Consume fish several times a week.
3. Avoid obesity and adjust overall energy intake to energy needs.
4. Increase intake of cereal bran fiber foods.
5. Consume more vegetables, soy products, and fruits, which are excellent sources of vitamins, antioxidants,anticarcinogens, minerals, and fiber.
6. Avoid salted, pickled, or smoked foods.
7. Limit the intake of fried or broiled foods, or “pretreat” to decrease the formation of carcinogens during cooking.
8 Increase intake of calcium magnesium with low-fat or skim dairy products, milk or yogurt, and certain vegetables.
9. Consume alcoholic beverages in moderation.
10. Drink 1 to 1.5 liters of water or fluids each day; tea contains anticancer antioxidants.
11. Be careful about exposure to sunlight. High-risk individuals, particularly of Celtic ancestry, should use sunscreen creams.
12. Exercise regularly, but only after o health check certifying normal blood pressure and serum cholesterol levels, to ensure cardiovascular potency.
B. Early detection
1. Self-examination. All women older than 20 years of age should examine their breasts 5 days after each menstrual period.
2. Screening. Unless the patient reports a specific symptom, most screening procedures are fruitless. Certain procedures have been found adequate to detect potentially curable cancers in asymptomatic people in a cost-effective manner.
a. Breast cancer;
b. Uterine cervical cancer;
c. Colorectal cancer;
d. Prostate cancer.
e. General screening. Yearly complete blood count is recommended to search for tumor-related iron deficiency anemia and other hematologic problems in older patients
Study tests for self-examination
Choose the correct answer/statement:
1. A cancer epidemiology is a branch of medical science that deals with the incidence, distribution, and control of disease in population.
A. Right
B. Wrong
2. An incidence rate is the number of new cases of cancer per 100,000 population per year.
A. Right
B. Wrong
3. At least 80 % of lung cancer is due to smoking.
A. Right
B. Wrong
4. Passive smoke doubles the risk for lung cancer.
A. Right
B. Wrong
5. Melanomas appear to be the result of genetic and environmental factors in addition to ultraviolet light.
A. Right
B. Wrong
6. Histological proof of malignancy remains the gold standard for diagnosis.
A. Right
B. Wrong
7. Staging systems are in continuous evolution.
A. Right
B. Wrong
8. Many staging systems are based on the tumor-node-metastasis (TNM) classification.
A. Right
B. Wrong
Students should be known:
1. Mechanism of carcinogenesis
2. Carcinogenic agents
3. Influence external and internal environmental factors on occurrence of tumors
4. Local growth and spread of tumors
5. Tumors types and grade of differentiation
6. Precancer diseases
7. Epidemiology and etiology of tumors
8. Incidence rate of cancer of the population of Ukraine now and perspective forecast
9. How changed the cancer incidence rates in Ukraine during last several decades.
10. The incidence of certain types of cancer.
11. Account and analysis of the incidence rate of cancer.
12. Organization of anticancer struggle.
13. Prevention of cancer.
14. Basic methods of diagnosis
15. Radiological examination (CT, MRI, chest radiographs) in oncology
16. Use radioisotopes in diagnosis of tumors
17. Use ultrasound as method of diagnosis
18. Endoscopic methods of diagnosis
19. Cytomorphological diagnosis
20. Immunodiagnostic
21. Classification of tumors by stages
22. Classification of tumors by the International system TNM
Students should be able to:
♦comment on the sequence of dysplasia, carcinoma in situ, and invasive cancer,
♦comment the influence of cigarette smoking on incidence of lung cancer,
♦comment the reduce the risk for lung cancer in patients who give up smoking,
♦explain different incidence the most common cancer in different region of Ukraine,
♦explain why lung cancer in Ternopil region is occupied the first place,
♦explain why skin cancer and melanoma are higher in South areas than in North,
♦comment the clinical classification of tumors by stages,
♦outline the rationale of the TNM classification system,
♦explain the relevance of staging,
♦identify three biopsy methods for obtaining tissue samples for examination,
♦describe features of exfoliative cytology,
♦describe features of fine needle biopsy,
♦take skin or nipple discharge for cytological examination,
♦prepare a patient for fine needle biopsy,
♦perform cyst aspiration for cytological examination,
♦perform physical examination of patient,
♦explain to patient how to perform self-examination.
Theme: PRINCIPLES OF TREATMENT AND FOLLOW-UP OF CANCER PATIENTS
Aim: to teach students
♦ to know the main treatment modalities of cancer patients;
♦ to know psychosocial problems of patients with cancer, deontology in oncology, general aspects of home care.
Professional motivation: Oncology is a multidisciplinary field of medicine. This means that several disciplines can be involved in the treatment of individual patients with cancer. An oncology team usually includes a surgeon, a pathologist, radiation oncologist and chemotherapist (medical oncologist).
Key words and phrases: treatment modalities, surgery: curative/radical, palliative, emergency; radiotherapy: external beam irradiation, fractioned dose, brachytherapy; chemotherapy, hyperthermia, photodynamic therapy, biologic/immunotherapy, gene therapy, hormonetherapy, adjuvant treatment,neoadjuvant, sequential/concurrent chemoradiotherapy, response (complete, partial), toxicity, performance status, deontology, supportive care, psychologic aspects, home care.
Work out of practical tasks.
In the Surgical Departments of Cancer Hospital student should learn the basics of multidisciplinary approach of cancer patients.
In the Outpatient Department of Cancer Hospital student should learn the main principles of follow-up of cancer patients.
Student’s self-learning programme:
A. Treatment modalities and possibilities
In cancer treatment there are three major treatment modalities: surgery, radiation therapy, and treatment with drugs (anticancer medicines). Which treatment modality will be chosen depends on many factors, such as: tumor type and its biological behavior, localization and the extent of the disease, the age and the general condition of the patient.
Curative or non-curative treatment
In oncology no treatment planning for any individual patient with cancer should be done before the diagnosis is confirmed microscopically and before the extent of the disease is evaluated. Treatment planning discriminates between treatment with curative intent and treatment that cannot aim at cure: non-curative treatment.
Cure for a patient with a malignant systemic disease is mainly ascertained by cancer drug treatment, whether or not combined with surgery and/or radiation therapy. This is especially true for several leukemia and malignant lymphomas.
Treatment of lymph node area
Because many malignant tumors can spread to the regional lymph nodes, there is always the question of whether a clinically normal lymph node region should be treated (by surgery or radiation therapy) simultaneously with the primary tumor.
Adjuvant treatment
Sometimes locoregional treatment with curative intent is combined with systemic drug treatment. Such treatment, with the intent to destroy possibly present distant micrometastases, is called adjuvant treatment.
Palliation
When there is no chance of cure after the evaluation of the extent of disease is completed, treatment planning aims at (temporary) arrest of the disease, or at palliation. Non-curative treatment is termed palliative treatment (or palliation), when it is only aimed at the treatment of complaints and symptoms due to the tumor or its metastases. Non-curative treatment is applied for the following reasons:
• maintenance of as good as possible quality of life,
• prevention of specific symptoms,
• treatment of complaints and symptoms,
• supportive care.
B. Surgery There are several ways in which cancer surgery is different from other disciplines of surgery. Due to the biological behaviour of most tumours cancer surgery is usually more extensive than non-oncological surgery. The surgeoeeds to know about:
• tumour characteristics and the biological behavior of the diverse site-specific tumours
• possibilities of radiation therapy, chemotherapy, hormonal and immunotherapy.
In treating a malignant tumour the surgeon has to keep in mind, among other things, that:
• the primary tumour has usually invaded the surrounding tissues to a greater extent than it apparently looks like
• there may be clinically non-assessable, but microscopically small metastases in the regional lymph nodes (micrometastases, occult metastases)
• clinically evidenced distant metastases in most cases make treatment with curative intent meaningless
• clinically non-assessable distant micrometastases may need in many cases – next to locoregional treatment with curative intent -complementary systemic treatment.
Every oncological surgical treatment with curative intent is aimed at complete removal of the tumour and possibly presents lymph node metastases. When an operation for a (suspected) malignant disease is performed, consideration must always be given whether and how the detrimental consequences of (possible) tumour spill can be prevented or can be met. This is because tumour spill can be the reason why treatment with curative intent becomes impossible, or that cure can only be pursued by a much more drastic treatment.
In cancer surgery there are a few basic rules that must be observed:
• the site and the direction of the skin-incision for surgery with curative intent depend on the optimal way in which the tumour can be adequately removed
• tumour and possibly present regional lymph node metastases are removed with an adequate margin of normal tissue
• scars of biopsies are considered to be contaminated with tumour cells and are removed en-bloc with thetumour
• during surgery, instruments that might be contaminated with tumour cells should be replaced
• needless manipulation has to be avoided
• after removal of the tumour the operation area should be rinsed with (cell-killing) liquid.
The most common surgical procedures in cancer management are:
• excision with small margins (biopsy),
• excision with large margins,
• excision en-bloc of the primary tumour and the regional lymph node area,
• lymph node dissection.
Less common surgical procedures in cancer management are:
• enucleating (only in selected cases with special indication)
• tissue destructive methods
• isolated regional perfusion
• excision of haematogenic metastases.
C. Radiation therapy
In radiation therapy ionizing radiation is used, either with:
• electromagnetic beam therapy (roentgen- and gamma beams)
• particle beam therapy (electron beams).
Roentgen- and electron beams are generated by orthovoltage and megavoltage equipment such as linear accelerators. Gamma beams are released from nuclear desintegration (radioactive sources such as cobalt- and cesium sources).
D. Cancer drug treatment
Cancer drug treatment options are:
• administering hormones
• administering drugs that interfere with natural hormone functions
• eliminating hormone producing organs
• administering cytostatic drugs
• administering biological response modifiers (immunotherapy: INF, IL).
Summary:
•Treatment with curative intent aims at cure. Non-curative treatment aims at the (temporary) arrest of the disease, or at prevention or treatment of specific symptoms.
•Palliative treatment aims at removing or diminishing complaints and/or symptoms, with the primary purpose of optimizing the quality of the remaining life.
• Non-curative treatment or palliative treatment is applied for the following reasons:
– maintenance of as good as possible quality of life
– prevention of specific symptoms
– treatment of complaints and symptoms (palliation)
– supportive care.
• Surgery and radiation therapy are locoregional treatment modalities. Drug treatment is usually systemic treatment.
• Elective treatment of a regional lymph node area is usually performed when there is a high risk of the presence of lymph node metastases (although not yet clinically evidenced).
• Adjuvant drug treatment is usually applied when there is a high risk of the presence of distantmicrometastases {although not yet clinically evidenced).
• In oncology follow-up is an important part of patient management.
• For several tumours follow-up is also important in the early detection of a second primary tumour.
• In the case of local or distant recurrences, treatment with curative intent can still be offered to several patients.
Tests and assignments for self-examination
Choose the correct answer/statement:
1. An oncology team usually includes a surgeon, a pathologist, and a radio/chemotherapist for planning of patients’ treatment.
A. Right
B. Wrong
2. Surgery and radiotherapy are locoregional treatment modalities. Drug treatment is usually systemic treatment.
A. Right
B. Wrong
3. In the case of local or distant recurrences treatment with curative intent can still be offered to patients.
A. Right
B. Wrong
4. When radioisotopes are administered into abdominal cavity this treatment is named as external radiotherapy.
A. Right
B. Wrong
5. Surgery procedures are used for patients with cancer are different from surgery procedures are used for patients with other diseases.
A. Right
B. Wrong
6. Preoperatively chemotherapy is called as adjuvant therapy.
A. Right
B. Wrong
7. Postoperatively chemotherapy is called as neoadjuvant therapy
A. Right
B. Wrong
Students should be know:
1. Multidisciplinary treatment modalities in Oncology.
2. Locoregional and systemic treatment of cancer patients.
3. Curative and non-curative treatment.
4. Treatment modalities of lymph node area.
5. Elective treatment.
6 Watchful waiting
7. Adjuvant treatment
8. Neo-adjuvant treatment
9. Palliative treatment
10. Different oncological surgical procedures
11. Explorative surgery.
12. External and internal radiotherapy
13 Sequential and concurrent chemoradiotherapy
14. Patient follow-up
Students should be able to:
♦explain why oncology is considered a multidisciplinary field of medicine
♦differentiate between locoregional and systemic treatment
♦explain the difference between curative and non-curative treatment
♦clarify the reasons why treatment of the regional lymph nodes are as are or are not included in the treatment of the primary tumor
♦explain adjuvant treatment
♦elaborate non-curative treatment, including palliation
♦explain the difference between cancer surgery and other disciplines of surgery
♦state basic rules of cancer surgery
♦define lymph node dissection
♦argue why enucleation is obsolete in cancer surgery
♦comment upon an explorative operation
♦state methods of radiation therapy
♦reflect upon the planning of a radiation therapy
♦discuss hormonal treatment in broad outline
♦comment upon the indications for cytostatic drugs
♦elaborate upon immunotherapy
♦explain the difference between sequential and concurrent chemoradiotherapy
References:
Basic:
1. Clinical Oncology. Textbook / Edited by: V.I. Starikov, A.S. Khodak and K.V. Barannikov. – Kharkiv, 2013. – 207 p.
2. Clinical Oncology. Textbook / Edited by: V. Sorkin, A. Popovich, Yu. Dumanskiy. – Simferopol, 2008. – 188 p.
3. Cancer Management: a multidisciplinary approach (Medical, Surgical and Radiation Oncology) / Edited by Richard Pazdur et al. – PRR, Melville, NY, 2006.
4. Textbook of Clinical Oncology. Second Edition, American Cancer Society, USA, Washington, D.C., 2005.
5. Cancer. Principles and Practice of Oncology. Vincent DeVita et al., USA, 2003.
6. TNM Classification of Malignant Tumours. 7th Edition / Edited by L.H. Sobin and Ch. Wittekind. – Willey-Liss, New York, 2010. – 239 p.
Additional:
1. Щепотін І.Б., Ганул В.Л., Кліменко І.О. та ін. Онкологія. Київ: Книга плюс, 2006. 496 с.
2. Вибрані лекції з клінічної онкології: Навч. посіб./ Бондар Г.В., Думанський Ю.В., Антіпова С.В., Попович О.Ю. та ін. – Луганськ, 2009. – 560 с.
3. Онкологія. Вибрані лекції для студентів і лікарів / За ред. В.Ф. Чехуна – Київ: Здоров’я України, 2010. – 768 с.
4. Рак в Україні, 2008-2009. Бюлетень Національного канцер-реєстру № 11 / За ред. І.Б. Щепотіна. – Київ, 2010. – 111 с.
5. Галайчук І.Й. Клінічна онкологія. Частина 1. – Тернопіль, Укрмедкнига, 2003.
Prepared by Prof. I.Y. Galaychuk.
Adopted at the Chair Meeting 07 June, 2013,
The minutes № 10,
