The Patient  With Cancer
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The Patient With Cancer



A detailed presentation on cancer, causes, treatment and management

A detailed presentation on cancer, causes, treatment and management



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The Patient  With Cancer The Patient With Cancer Presentation Transcript

  • Patient with Cancer
    • Carcinogenesis : It is the process whereby external influences cause cancer
    • This can be divided into:
      • Irritation-in which cells undergo transformation into a pre-malignant stage.
      • Promotion-in which these cells are induced to form a tumour
  • Patient with cancer
    • The agents which cause cancer are termed as carcinogens and many carcinogens that affect humans have been identified.
    • 1. Polycyclic aromatic
    • hydrocarbons,(PAHs);Tobacco smoke, eg;
    • Benzopyrine and 3-methylcholantherene causing Lung cancer
    • 2.Infective agents such as Human papilloma virus in causing CA of uterine CX, Viruses in Nasopharyngeal cancer, Burkitt’s Lymphoma, Hepatocellular carcinoma, T-cell leukaemia and Kaposi’s sarcoma
  • Patient with cancer
    • Oncogenes;
    • These are actually normal genes which have become mutated, and transforming viruses ,transfer these genes from a previously infected host
    • Physico- chemical agents on the other hand cause direct damage to genes with in the cell
  • Patient with cancer
    • Diet ; may have an important role in carcinogenesis. Heavily cooked meat is rich in heterocyclic amines are powerful carcinogens
    • High vegetable intake in contrast is associated with low rates of cancer.Both vegetables and fruits are rich in antioxdants and this may have protective effect,eg;Brocoli,Brussel sprouts
  • Patient with cancer
    • Diet and energy intake: There is a positive association between obesity and cancer and a negative association between excercise and cancer.
    • Calorie restriction decreases the rate of cellular division in many tissues as seen in animal studies
    • Diet may affect cancer incidence by,1.acting as a source of envioremental carcinogens, 2.acting as a source of protective substances and,3 . affecting the rate of cellular proliferation
  • Patient with cancer
    • Molecular genetics in cancer
    • Tumorogenesis is a multi step process that evolves as a result of the accumulation of a number of genetic mutations.
    • Two major categories of genes involved in tumorogenesis are: ONCOGENES and TUMOUR SUPRESSOR GENES
  • Patient withCancer
    • Cancer may present clinically with symptoms and signs of:
    • 1.the primary tumour- with mass,obstruction,bleeding
    • 2,spread to the regional lymph nodes
    • 3,spread by the blood stream-metastasis to brain,lungs,liver and bone
    • 4,Nonspcific effects-tiredness,malaise ,LOW,LOAetc
    • 5,Paraneoplastic syndromes-neuropathy,skin problems,anaemia eg Renal cell carcinoma
  • Patient with cancer
    • B.Pathgenesis : Abnormal motility of these malignant cells
    • C.Breakdown of extracellular matrix
    • Malignat tumours can be defined by their ability to invade locally and to metastasise to distant organs.
    • Invasion is thought to be due to combination of:
    • a.Increased pressure produced by rapidly dividing cells
    • b.Abnormal motility of these malignant cells
    • c.Breakdown of the extracellular matrix by factors produced by the tumour cells
  • Patient with Cancer
    • Predominant tumours metastsising to liver lung and bone
    • Site of primary Common sites of Mets
    • Lung Bones,Liver Lung
    • Colon Liver
    • Rectum Liver ,lung
    • Breast Liver Lung and Bone
    • Prostate Bone
    • Ovary Liver, lung
    • Stomach Liver
    • Pancreas Liver
    • Head and Neck Lung
    • Thyroid Bone
    • Urogenital Tract Lung
    • Bladder Liver,lung Bone
    • Melanoma Liver, lung
  • Patient with cancer
    • Clinicopathological staging is essential for 3 main reasons:
    • a, It gives an estimate of the prognosis
    • B ,Useful in planning treatment
    • c, Allows estimation of casemix which is vital for interpretation of data and comparison of results from different centres
    • ,
  • Patient with Cancer
    • Histological diagnosis requires biopsy.
    • Types of biopsy:
    • Incisional biopsy- for tumours deemed inoperable
    • Core needle biopsy-Ca breast
    • Endoscopic biospy forGI cancers
    • Fine Needle Aspiration Biopsy(FNAB)
    • Excisional biopsy
  • Patient with Cancer
    • TNM Classification –which has been adopted by UICC(Union Internationale Contre le Cancer)
    • Tumour, Node & Metastasis
    • T-extent of spread
    • N-extent of spread to the lymph nodes
    • M-the presence or absence of metastasis
  • Patient with cancer
    • Screening for Cancer involves detection of disease in asymtomatic population in order to improve outcomes by early dignosis eg; Screenig for FAP gene in Colorectal carcinoma,BRCA 1&2 in Cancer Breast, PSA estimation to detect Prostatic cancer etc.
    • Screening test must be safe,acceptable to the population, relatively cheap,sensitive and Spcific
  • Patient with Cancer
    • Needs Compassion
    • Competent and Committed staff
    • Results are excellent if cancers are diagnosed early.
    • All efforts must be aimed at early diagnosis
  • Patient with cancer
    • Multidisciplinary team in cancer treatment
    • The team comprises of surgeons oncologists, pathologists, radiologists, and often specialist nurses
    • The core team must maintain good communication with primary care, palliative care and rehabilitation services
  • Patient with Cancer
    • Histological grading is is also important as it carries prognostic significance and may be complementory to TNM staging
    • Most tumours are subdivided into:
    • Well-differentiated
    • Moderately differentiated
    • Poorly differentiated depending on Pleomorphism of cells and attempts at gland formation as in adenocarcinomas
  • Patient with cancer
    • Surgery ;
    • The main aim of cancer surgery is local control
    • Local control equates to cure when the disease is localised
    • Surgery can be diagnostic, curative, palliattive or reconstructive
  • Patient with Cancer
    • Laparoscopy - is widely used for staging of intra-abdominal malignancy particularly oesophageal and gastric cancer. It is often possible to diagnose widespread peritoneal disease and small liver metastasis which may have been missed in cross-sectional imaging by lapparoscpy.Laparoscopic ultrasound is particularly useful for diagnosing intrahepatic metastasis
  • Patient with cancer
    • Role of Surgery in other cancers : eg:Orchidectomy for carcinoma of testis, and lymph node biopsy in patients with lymphoma
    • Recently sentinel node biopsy in Melanoma and Breast cancer has attracted a great deal of interest
  • Patient with cancer
    • Removal of primary disease
    • Radical surgery for cancer involves removal of the primary tumour and as much of the surrounding tissue and lymph nodes in order to achieve local control but also to prevent spread of tumour through lymphatics. At least 2cms healthy tumour free margin must be ensured in curative surgery.
  • Patient with Cancer
    • Palliation : In many cases Surgery may not be curative: eg a patient with symptomatic primary tumour who has a distant metastasis. Removal of the primary tumour may increase the patient’s quality of life although it will have little effect on the ultimate outcome. Examples of palliative surgery are: By pass procedures on Cancer head of pancreas causing obstructive jaundice or cancer stomach.
  • Patient with cancer
    • Surgery for prevention- there are some clear indications for surgery in the prevention of cancer eg: Panproctocolectomy with or without an ileal pouch for a patient with FAP will prevent the development of colorectal cancer which otherwise will be inevitable
    • Colectomy advised for a patient with ulcerative colitis who has high grade dysplasia on biopsy
    • Bilateral mastectomy is also recommended for lobular carcinoma in situ which is sometimes requested by the pt with a strong family h/o breast cancer
  • Patient with cancer
    • Reconstruction -After surgical excision of solid tumour reconstruction is an integral part of an;Reconstruction of the breast after mastectomy, or after head and neck surgery or restoration of the continuity of the gut after resection of gut tumour
  • Patient with cancer
    • Radiotherapy:
    • Modern radiotherapy is delivered in the form of megavoltage X-rays or gamma rays which generate high energy <1.10x6V
    • Advantages are:
    • 1,Deep seated tumours can be treated
    • 2,Absorption of radiation is similar in all tissues
    • Lower energy X-rays may be used to treat skin cancers and may be of value in palliation
  • Patient with Cancer
    • Chemotherapy - acts at a molecular level
    • They may be in the form of Alkylating agents eg;Cyclophosphamide, nitrogen mustard-bind to proteins or DNA
    • Anti metabolites,eg:5-Flurouracil , methtrexate,6-mercaptopurine-induce celldeath or prevent replication
    • Vinca alkaloids,eg : vinblastine and vincristin-arrest cell mitosis
  • Patient with Cancer
    • Antibiotics –Adrimycin,bleomycin,actinomycinD. MitomycinD
    • They bind the double stranded DNA and prevent replication
  • Patient with cancer
    • Hormone Therapy :
    • Some types of cancer notably of Breast,Endometrium,Prostate are hormone sensitive
    • They exert their activity on cells by means of blocking the receptors which bind the hormone.Steroid hormones bind cytoplasmic receptors.Peptide hormones bind to receptors that are integral to the cell membrane resulting in transcription and translocation
  • Patient with Cancer
    • Immunotherapy - based on the concept that cancer cells might be specifically antigenic or immune response is diminished in cancer pts
    • BCG ,Cornibacterium or levamisole
    • Interferrons –gamma has been shown to have anti tumour activity and is used widely in some of the uncommon leukaemias
  • Patient with cancer
    • Gene therapy -introducing a gene into cancer cells. Trials are on using a vector such as a retro virus or an adeno virus. Results are promising but not well substantiated.
    • Biological modifiers show great promise both as single and in combination with conventional chemotherapy. eg:Metallproteinase inhibitors, Epidermal growth factor(EFG)receptor antagonists and cyclin-dependent kinase(CDK) inhibitors
  • Patient with cancer
    • In summary :
    • Cancers are curable if detcted early
    • Every effort must be made by the clinicians to diagnose cancer early.
    • Treatment involves multi disciplinary team effort by dedicated team of specialists
    • Tender loving care can make world of difference for a cancer patient
  • Patient with cancer
    • The author has successfully recovered from Cancer of the left maxillary antrum after having undergone radical maxillectomy surgery with neck disection followed by radio therapy and chemotherapy.
    • You may contact the author by email at -
    • [email_address]
    • © 2007-08 Dr C S Venkatesh. All Rights reserved.
    • Professor of Surgery, University Kuala Lumpur – Royal College of Medicine, Perak. IPOH Malaysia