Trajectory of Cancer Care

The continuum of cancer care spans prevention, early detection and screening, diagnosis and treatment of new cancer cases, care of survivors, palliative care, and finally, support for terminally ill patients and their families (Mandelblatt et al., 1998). In this section, phases of cancer care are described beginning with early detection and screening. Primary prevention (efforts to prevent the occurrence cancer) is outside the scope of this report. (Much of this section is adapted from Ganz, 1996.)

Early Detection and Screening

The goals of early detection and screening are to identify cancers before they invade nearby tissue or spread to new sites. Visual examination of the colon using a colonoscope, for example, can find polyps that can be removed before they turn into invasive tumors. Other common screening and early detection methods are mammography, testing for bleeding in the digestive tract, Pap smears of the cervix, blood tests for prostate-specific proteins, and examination of the skin surface. Early detection of cancer is also influenced by attention to symptoms of cancer (e.g., blood in stool, lump in breast) and prompt follow-up. Once cancer is detected by screening or because of symptoms, the diagnostic evaluation phase of cancer management begins.

Diagnostic Evaluation

When a cancer screening test is positive or symptoms lead to its detection, further examinations are conducted to confirm the diagnosis and make it more precise. Pathologists attempt to identify the type of cell causing the cancer and may try to identify prognostic factors from a biopsy or tumor removed surgically to judge whether the cancer is fast growing or slow growing. Breast cancer tissue, for example, is usually examined for the presence of hormone receptors. If the receptors are present, therapy with hormone-blocking drugs may be prescribed to prevent a recurrence. Results of diagnostic and prognostic tests may be reviewed by a team of specialists as a decision is made on the first approach to treatment. Most newly diagnosed cancer patients go through a series of staging tests, including blood tests, x-rays, and various types of scans, to determine the extent of the disease. Initial planning is unusually important for many types of cancer, because choice of the first treatment severely limits subsequent treatment options due to the nature of cancer progression.

Primary and Adjuvant Treatment

Traditionally, most cancers have been treated with surgery, radiation, chemotherapy, or some combination of the three. Surgery has the longest history and is the mainstay of primary treatment for solid tumors (i.e., most cancers other than leukemias and lymphomas). For cancers



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