General principles involved in cancer treatment and Detailed treatment of cervix cancer

1. General Principle of
Cancer And cervix Cancer
2016

2. Stats…
2Siegel et al: CA Cancer J Clin 2014
http://www.neeman-medical.com/sites/default/files/files/Cancer%20in%20India.pdf Accessed on 28.4.16

3. What Is Cancer?
• Cancer/Neoplasia – a large group of diseases
characterized by the uncontrolled growth and spread of
abnormal cells
• Malignant - cancerous
• Benign - noncancerous
3Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

4. What Is Cancer? – cont.
• Metastasis – malignant tumors that are not enclosed in a
protective capsule have the ability to spread to other organs
• Mutant cells – disruption of RNA and DNA within normal cells
may produce cells that differ in form, quality and function
from the normal cell
4Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

5. What Causes Cancer?
• External Factors – chemicals, radiation, viruses, and
lifestyle
• Internal Factors – hormones, immune conditions, and
inherited mutations
• Theories
• Cellular change/mutation theories
• Carcinogens
• Oncogenes/ protooncogenes
5Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

6. Factors Believed to Contribute to Global
Causes of Cancer
6Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

7. Diagnosis
• To diagnose the presence of cancer, biopsy is performed
• Biospy
• A biopsy is the surgical removal of a small piece of tissue for
microscopic examination
• Microscopic examination will reveal, tumor is
• Malignant (cancerous)
• Benign (non- cancerous)
• There are three ways tissue can be removed for biopsy:
• Endoscopy
• Needle biopsy
• Surgical biopsy
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

8. Diagnosis
• Endoscopy
• Done by using a thin lighted tube
• Needle Biopsy
• Small tissue sample is taken by inserting a needle into the abnormal
(suspicious) area
• Surgical Biopsy
• Excisional biopsy
• Removes the entire tumor, often with some surrounding normal tissue
• Incisional biopsy
• Removes just a portion of the tumor
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

9. Staging
Kasper et al, Harrison's Principles of Internal Medicine,
19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles &
Practice of Oncology 10th Edition

10. Cancer treatment modalities
• Can be used alone or in
combination
• Outcome measured in
terms of survival rates and
response rates
10Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

11. Target Areas for Therapeutic
Interventions
11
Invasivity
Motility
Aneuploidy
Angiogenesis
Imune Defense
Evasion
Deregulated
Proliferation
Altered Energy
Metabolism
Immortalization
(Anti-Apoptosis)
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

12. Principles of Surgery – Cancer
• For most solid tumors, surgery remains the definitive treatment
• Role of surgery in cancer treatment include –
• Diagnosis & staging
• Ultrasound & Biopsy
• Sampling Lymph nodes
• Removal of primary disease
• Removal of primary tumour + lymph node
• Removal of metastatic disease
• Liver metastases – Resection
• Lung metastases – Pulmonary resection
• Palliation
• By pass procedures

13. Principles of Non-surgical Treatment –
Cancer
• In contrast to surgery, it is possible to construct dose–
response relationships for both the benefits (such as
tumour cure rate) and harms (such as tissue damage that
is both severe and permanent) associated with non-
surgical interventions
• Principle of selective toxicity
• Treatment must be delivered in such a way as to ensure that the
damage done to the tumour is more than the damage done to
the normal tissues.
• General Strategy
• Spatial distribution of therapies / Adjuvant therapy .
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

14. Radiotherapy
• Radiation therapy are reasonably straightforward
• Define the target to treat
• Design the optimal technical set-up to provide uniform
irradiation of that target
• Choose that schedule of treatment that delivers radiation to
that target in such a way as to maximize the therapeutic ratio
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

15. “5 R’s” – Radiotherapy
• Repair of cellular damage
• Reoxygenation of the
tumour
• Redistribution within cell
cycle
• Repopulation of cells
• Radiosensitivity
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

16. Chemotherapy
• Selective toxicity is the fundamental principle underlying the
use of CT in clinical practice
• CT, by itself rarely sufficient to cure cancer
• Principle of Combined Therapy
• Combat drug resistance
• Use effective agents
• Agents with different modes of action (synergy)
• Agents with non-overlapping toxicities
• Consider spatial co-operation
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

17. Mechanisms of traditional
Chemotherapy
These drugs act on rapidly dividing cells, which include normal tissues (e.g., hair,
gastrointestinal epithelium, bone marrow) in addition to cancer cells

18. Hormonal Therapy
• It involves the manipulation of the endocrine system
through exogenous administration of specific hormones
• Which inhibit the production or activity of such hormones
(hormone antagonists)
• Hormonal therapy is used for several types of cancers
derived from hormonally responsive tissues
• Breast, prostate, endometrium, and adrenal cortex
18Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

19. Targeted Therapies
• Allow the cancer treatment
to “target” a certain cancer
cell by interfering with the
natural functions of tumor
growth
• They “target” specific parts
of a cancer cell or its
actions
Mechanisms of targeted therapies
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th
Edition

20. Classification of Targeted therapies
• Targeted cancer agents are broadly classified as
• Therapeutic monoclonal antibodies
• Target specific antigens found on the cell surface, such as transmembrane
receptors or extracellular growth factors
• In some cases, monoclonal antibodies are conjugated to radio-isotopes or toxins
to allow specific delivery of these cytotoxic agents to the intended cancer cell
target
• Small molecules
• Penetrate the cell membrane to interact with targets inside a cell
• Usually designed to interfere with the enzymatic activity of the target protein.
20
Gerber D E, 2008, American Family Physician

21. Palliative Therapy – Principles
• Symptom relief
• Psychosocial interventions
• Physical & practical support
• Information & knowledge
• Nutritional support
• Social support
• Financial support
• Spiritual support
Gerber D E, 2008, American Family Physician

22. Cervix Cancer

23. Diagnosis(1/3)
Physical Examination PAP Test HPV TestPelvic Examination
Initially
If the Pap test showed some abnormal cells, and the HPV test is also positive,
the doctor may suggest 1 or more of the following diagnostic tests:
Colposcopy Biopsy
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th
Edition

24. Diagnosis(2/3)
Colposcopy A colposcope is used to look at the cervix. The colposcope
combines a bright light with a magnifying lens to make tissue
easier to see. A colposcopy is usually done in the doctor’s office
or clinic.
Biopsy Biopsy under local anesthesia and pathologists then check the
tissue under a microscope for abnormal cells.
Punch biopsy: Uses a sharp tool to pinch off small samples of
cervical tissue.
LEEP: Uses an electric wire loop to slice off a thin, round piece
of cervical tissue.
Endo-cervical curettage: Uses a curette (a small, spoon-
shaped instrument) to scrape a small sample of tissue from the
cervix
Conization: Removes a cone-shaped sample of tissue. Lets the
pathologist see if abnormal cells are in the tissue beneath the
surface of the cervix.
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015), DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

25. Diagnosis(3/3)
• If the biopsy indicates that cervical cancer is present
• Additional tests are done to see if the cancer has spread
beyond the cervix
• Pelvic examination
• X-ray
• Computed tomography (CT or CAT) scan
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET) or PET-CT scan
• Cystoscopy
• Proctoscopy (also called a sigmoidoscopy)
• Laparoscopy
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

26. Grades of Dysplasia
Kasper et al, Harrison's Principles of Internal Medicine, 19th Edition (2015)
DeVita, Hellman, and Rosenberg’s, Cancer Principles & Practice of Oncology 10th Edition

27. Staging: NCCN Guidelines 2016
NCCN Guideline 2016

28. Management of Cervix Cancer
NCCN Guideline 2016

29. Management of Cervix Cancer
NCCN Guideline 2016

30. Management of Cervix Cancer
NCCN Guideline 2016

31. Management of Cervix Cancer
NCCN Guideline 2016

32. Management of Cervix Cancer
NCCN Guideline 2016

33. Management of Cervix Cancer
NCCN Guideline 2016

34. Management of Cervix Cancer
NCCN Guideline 2016

35. Management of Cervix Cancer
NCCN Guideline 2016

36. Management of Cervix Cancer
NCCN Guideline 2016

37. Management of Cervix Cancer
NCCN Guideline 2016

38. Chemotherapy Regimens For Recurrent
Or Metastatic Cervical Cancer
NCCN Guideline 2016

39. Thank You