3. Page 3
Sobre el cáncer, en general…
Curable en casi 2/3 de los pacientes
Evento catastrófico para el paciente y su entorno
Cambio en la imagen propia, familiar y social
Todo el cuerpo está enfermo – es una traición…
Nada nunca será igual
1
2
3
4
5
Algunas notas
8. Page 8
Cáncer en el mundo
7.6 millones
Hepatocelular (2x)
Cérvix uterino (2x)
Esófago (2-3x)
12.7 millones
Pulmón (2x)
Mama (3x)
Próstata (2.5x)
Colon y recto (3x)
Estadísticas en 2008: Prevalencia – 25 millones
9. Cáncer:
7.6 millones de muertes / año
20.000/día… 14/minuto…
Aproximadamente la población de:
• Suiza
• Israel
• Bulgaria
19. Page 19
Epidemiología del cáncer
Pulmón
Estómago
Hígado
Colon y recto
Mama
Esófago
Mundo
Pulmón
Colon y recto
Mama
Páncreas
Próstata
Leucemia
Estados Unidos
Estómago
Próstata
Pulmón
Mama
Cérvix
Colon y recto
Colombia
Mortalidad - Mundo, Estados Unidos, Colombia
20. Testículo Mama Hodgkin Próstata Vejiga Colon Ovario Pulmón Páncreas
Supervivencia
masculina
Supervivencia
femenina
Muerte
No todos los cánceres son igualmente
letales
43. Pain
Setting Prevalence
Diagnosis 25-30%
Treatment associated 20%
Progressive disease 75%
Mechanism
By the tumor 70%
Caused by treatment 20%
Unrelated to cancer 10%
Treatment options
Pharmacologic intervention Will help in 85%
Antitumor therapy
Neurostimulation
Regional analgesia
Neuroablative
Refractory to all measures About 3%
Harrison’s, 19th Ed, 2015
48. Taste
Change
Taste
Change
C et al. Support Care Cancer. 2005C et al. Support Care Cancer. 2005
Throm
bocytopenia
Throm
bocytopenia
MedianVASScores
Rem
ission
Rem
issionCINV
1
CINV
1
CurrentHealth
CurrentHealthAlopecia
Alopecia
Depression
Depression
Ototoxicity
Ototoxicity
W
eightGain
W
eightGain
SexualDysfunction
SexualDysfunction
M
em
oryloss
M
em
oryloss
Constipation
ConstipationLeg
pain
Leg
painFatigue
Fatigue
Flu
Flu
PeripheralNeuropathy
PeripheralNeuropathy
Diarrhea
Diarrhea
Dysuria
Dysuria
CINV
4
CINV
4CINV
6
CINV
6CINV
5
CINV
5Death
Death
PerfectHealth
CINV
2
CINV
2
M
ucositis
M
ucositis
CINV
3
CINV
3
Febrile
Neutropenia
Febrile
Neutropenia
CompleteComplete
ControlControl
Mucositis
Death
Moderate Delayed NauseaModerate Delayed Nausea
Poorly ControlledPoorly Controlled
Acute & Delayed CINVAcute & Delayed CINV
Chemotherapy Experienced PatientsChemotherapy Experienced Patients
Rank Severe CINV Near DeathRank Severe CINV Near Death
49. 49
Mecanismos de las Náuseas y Vómito
inducidos por la quimioterapia
Quimioterapia
Central
Periférica
50. 50
Mecanismos de las Náuseas y Vómito
inducidos por la quimioterapia
C. Enterocromafín
Liberación de
serotonina
Quimioterapia
Periférica
51. 51
Mecanismos de las Náuseas y Vómito
inducidos por la quimioterapia
C. Enterocromafín
Liberación de
Serotonina
Aferentes vagales
receptores de 5-HT3
Quimioterapia
Periférica
52. 52
Quimioterapia
Mecanismos de las Náuseas y Vómito
inducidos por la quimioterapia
Complejo Dorsal
Vagal – área
postrema
Periférica
Central
C. Enterocromafín
Liberación de
Serotonina
Aferentes vagales
receptores de 5-HT3
53. 53
Quimioterapia
Mecanismos de las Náuseas y Vómito
inducidos por la quimioterapia
Receptores
NK1 de Sustancia P
Periférica
Central
Complejo Dorsal
Vagal – área
postrema
C. Enterocromafín
Liberación de
Serotonina
Aferentes vagales
receptores de 5-HT3
55. Nutrition
Weight loss Decreased appetite, citokynes, altered
metabolism
When to intervene?
10% unexplained weight loss
Serum transferrin 150 mg/dL or less
Ablumin 3.4 gr/dL, o less
How to intervene?
Enteral preferred over parenteral
Harrison’s, 19th Ed, 2015
56. RECIST: Response Evaluation Criteria In Solid Tumors
Change in the sum of the longest diameters
↑20% (or new lesion): Progressive disease
↓30%: partial response (PR)
↓100%: unconfirmed complete response (uCR)
↓100% + Negative biopsy: complete response (CR)
58. Tobacco Comments
Risk factor Cardiovascular disease, pulmonary
diseasse and cancer
Tobacco-related death 1/3 of smokers
Cancers Lung, laryng, oropharynx, esophagus,
kidney, bladder, pancreas, and stomach
Risk after quitting 30-50% lower 10-yr lung cancer
mortality
Second-hand smoke also harmful
Early adoption 80% smokers begin befor age 18
Cigars also increase cancer risk Oral and esophageal cancer
Smokeless tobacco also increases
cancer risk
Oral cancer
Benefits of e-cigarettes unclear
Harrison’s, 19th Ed, 2015
59. Physical inactivity Comments
Risk factor Colon and breast cancer
Some biases may obscure this relationship
Harrison’s, 19th Ed, 2015
60. Diet modification Comments
High fat diet increases risk of Breast, colon, prostate, endometrium
High dietary fiber decreases the risk Colonic polyps and colon cancer
High fruit and vegetable intake NOT
proven of benefit
RCT
Low-fat, High fiber diet faild to decrease
risk of colonic polyp
RCTx 2
No dietary intervention has proven
effective in preventing cancer
WHI
Harrison’s, 19th Ed, 2015
61. Energy balance Comments
Obesity increases risk of Colon, breast (postmenopausal),
endometrial, kidney, esophagus (GEJ)
Magnitud of the effect
Colon cancer RR 1.5-2 in males, 1.2-15 in females
Breast cancer Risk increases by 30-50%
Adipose tissue harbors aromatase that
can create estrogen from androgens
Harrison’s, 19th Ed, 2015
63. Sun avoidance Comments
Cumulative exposure to UV radiation Non-melanoma skin cancers
Intermittent acute sun exposure Melanoma (maybe)
Protective clothing, reduction of sun
exposure
Reduce risk of skin caner
Sunscreen Decreases risk of actinic keratoses
No evidence of decrease risk of
melanoma
Freckling High risk of skin malignancies
Risk factors for melanoma Sunburns, large number of melanocytic
nevi, and atypical nevi
Harrison’s, 19th Ed, 2015
65. Chemoprevention Comments
Upper aerodigestive tract and lung Smoking cessation
HPV vaccination
B-carotene increases lung cancer risk
Colon cancer Aspirin (75 mg QD) dicreases colon cancer risk by
24%
Cox-2 inhibitors increase CV risk, so studies on
cancer chemoprevention were abandoned
High calcium diets decrease CRC risk (not
supperted by the WHI)
Estrogen + progestin decreases CRC risk by 44%
(WHI)
Statins may decrease CRC risk
Breast cancer Tamoxifen dicreases BC risk by 49%
Raloxifen and Exemestane ara also effective
chemopreventive strategies for women with
high risk (1.55% 5-yr risk) of BC
Prostate cancer Finasteride and Dutasteride dcrease low-grade,
but increase high-grade prostatic cancer. No
survival benefit
Vitamin E supplementation increases prostate
cancer risk
Harrison’s, 19th Ed, 2015
66. Vaccine and cancer prevention Comments
Hepatitis B and C are related to
liver cancer
Hepatitis B vaccination has proven effective for
B-hepatitis and hepatomas
HPV are linked to cervical, anal
and head and neck cancers
HPV vaccination may decrease cervical cancer
risk by 70%, but studies are ongoing.
Vaccination of females and males is
recommendd in the US at ages 9-26
H. Pylori is related to gastric
adenocarcinomas and gastric
lymphoma
No vaccination stretegy exists
Surgical prevention of cancer
Cervical dysplasia Conization
FAP or UC Colectomy
BRCA1/BRCA2 Prophylactic bilateral mastectomy
Prophylactic oophorectomy
Breast cancer Prophylacti oophorectomy (in premenopausal
women)
Harrison’s, 19th Ed, 2015
68. Breast cancer screening Comments
Mammography Q1-2 years, 50 and older: decreases BC by 15-
30%
Benefits in less than 50 less clear
High false positive rates
High risk of overdiagnosis
Considerable amount of overdiagnosis has
ensued in the US
BSE No evidence of benefit in BC detection or
mortality
Breast MRI May be effective in BRCA1/2 carriers (not
proven in prospective trials)
Harrison’s, 19th Ed, 2015
69. Cervical cancer screening Comments
Pap-smear Begin at age 21, every 3 years, up to age 30.
At 30, Pap-smear + HPV testing may be offered. If
both negativa, screening can be decreased to q5
years
Stop at 65 in women with 10 years history of
normal screening tests
Screening may be discontinued after
histerectomy for non-oncologic reasons
Harrison’s, 19th Ed, 2015
70. CRC screening Comments
FOBT 15% risk reduction
False positive in 1-5%
Only 2-10% of positive tests have cancer
Fecal immunochemical tests have higher sensitiviity
Fecal DNA tests may be superior to FOBT, but studies are
ongoning
Sigmoidoscopy Decreases CRC risk by 18%, and mortality by 28%
Should be performed between ages 50-74
Optimal interval unknown, 5 year interval recommended
Colonoscopy Detects 25% more advanced lesions than FOBT +
sigmoidoscopy
Perforation risk 3/1000
Expensive
Start at 50, q10years, up to 70
CT colonography Comparable to colonoscopy
High incidence of incidental findings of unknown significance
(15-30%)
High radiation risk
Harrison’s, 19th Ed, 2015
71. Prostate cancer screening Comments
DRE + PSA Dramatic increase in prostate cancer diagnosis
Unclear overall benefit due to lead-time bias,
length-bias, and overdiagnosis
False positive results induce invasive testing
Even true positive results may not always detect
cancers that will impact survival
Two major trials with conflicting results
American PLCO: negativa (but close to half the
control group underwent opportunistic PSA
evaluation)
European ERSPC: positive. But, to avert 1 death,
more than 1000 patients needed to be screened,
and 37 prostate cancers needed to be detected
Screen detected low-grade prostate cancer
therapy may cause more harm than good.
UPSTF recommends against routing prostate
cancer screening
ACS recommends PSA and DRE starting at age 50,
in highly motivated men, fully informed of the
poetnatial consequences
Harrison’s, 19th Ed, 2015
72. Lung cancer screening Comments
LD CT 15-20% reduction of lung cancer mortality (about
3/1000 screened)
Yearly, 55-74, in heavy smokers (30ç ppy)
High incidence of incidental findings
Radiation exposure
CXR Ineffective
Harrison’s, 19th Ed, 2015
Editor's Notes
Preliminary preference (utility) data from nausea and vomiting health states from 3 studies involving ovarian cancer patients, clinicians, and healthy female controls were evaluated.
Preferences were assessed using the visual analog scale (VAS), with scores ranging from 0.0 (worst) to 1.0 (best).
Definitions of CINV were:
CINV 1 - Days 1-5 = little to no nausea or vomiting.
CINV 2 - Day 1 = complete control; Days 2-5 = moderate nausea, no vomiting.
CINV 3 - Day 1 = complete control; Days 2-5 = moderate nausea, severe vomiting.
CINV 4 - Day 1 = nausea and vomiting; Days 2-5 = moderate nausea.
CINV 5 - Day 1 = nausea and vomiting; Days 2-5 = moderate nausea, severe vomiting.
CINV 6 - Day 1 = complete control; Days 2-5 = severe nausea.
Patients rated significant CINV (CINV 3-6) comparable to the score for death.
1. Sun C, Bodurka D, Donato M et al. Nausea and vomiting side-effects of cancer therapies: preference assessments from patients, health care providers and healthy women. Support Care Cancer. 2002:10:378. Abstract #93.
