Diagnosing and Treating Adult Cancers and Associated Impairments (2021) / Chapter Skim
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4 Diagnosis, Staging, and Treatment of Cancer
4 Diagnosis, Staging, and Treatment of Cancer
Pages 71-106
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From page 71... ...
Those who are cancer free with no evidence of disease and those with chronic, stable, or intermittent disease will typically undergo routine surveillance for recurrent and new cancers. If, months to years later, a cancer survivor experiences a recurrence or new primary cancer, she or he may re-enter the trajectory with a new diagnosis and treatment plan.
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Recurrent and New Treatment with (f) Recurrence or Primary Cancers Noncurative Intent Disease New Primary Progression Cancer FIGURE 4-1 The cancer care trajectory.
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From page 73... ...
and the tumor's anatomic characteristics are what determine the treatment plan. Ideally, although not always in practice, the clinical cancer care team works with the patient -- and caregivers if appropriate -- to decide the best treatment strategy.
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Preventive Services Task Force (USPSTF) and the American Cancer Society, have developed screening recommendations for cancers.
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. † The American Cancer Society recommends initiating colorectal cancer screening at age 45 (Smith et al., 2019)
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testing instead of Pap smears for cervical cancer and fecal DNA testing instead of colonoscopy for colorectal cancer screening)
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. For certain cancers, direct visualization may also be useful (e.g., colonoscopy for suspected colon or rectal cancer or bronchoscopy for suspected lung cancer)
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From page 78... ...
For example, a patient with cancer diagnosed as a single lump in the breast without spread to the local lymph nodes or distant organ sites would be classified as early-stage. An advanced-stage lung cancer might present as a primary tumor of the lung with evidence that it has spread to the liver, bones, brain, or other sites.
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From page 79... ...
MRIs are commonly used to identify the presence of brain metastases for cancers that frequently spread to the brain (e.g., lung cancers)
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From page 80... ...
. Lung cancers may be further classified by whether the cancer cells exhibit specific abnormalities in cancer driver genes,1 such as mutations of the epidermal growth factor receptor gene or a chromosomal translocation of the ALK gene, or by their expression of the programmed death ligand-1 (PD-L1)
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From page 81... ...
NGS and other emerging biomarkers are generally more useful in patients with advanced, metastatic cancer, where these tests can help to identify a relatively small number of patients who may benefit from targeted systemic therapies. At present, NGS and other emerging biomarker tests are of limited use in most patients with early- or intermediate-stage disease, who are often best treated with local therapies (i.e., surgery and radiation therapy)
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From page 82... ...
Systemic treatments are carried by the circulatory system and can travel throughout the body to treat even widely metastatic cancers. Some systemic therapies, such as endocrine therapies, may be used for months or years after a patient is diagnosed with cancer.
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From page 83... ...
Therapeutic Goals Local and systemic therapies can be used for different patient objectives. The term "therapeutic intent" describes the goal of a cancer treatment plan, and therapeutic intent can be generally categorized as either "curative" or "palliative." However, these descriptors can be misleading, as not all patients receiving curative-intent therapies will be cured, and not all patients receiving palliative-intent therapies have symptoms in need of palliation.
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The committee notes that despite the availability of these guidelines, numerous studies have shown that cancer care often does not adhere to existing recommendations, including recommendations to engage patients in shared decision making with a multidisciplinary care team to determine their treatment plan and monitor adverse effects. Adherence to guidelines varies across the types of cancer, patient characteristics such as race/ethnicity and socioeconomic status, geography, insurance coverage, patient preferences, and physician recommendations (Bierbaum et al., 2020; Bristow et al., 2015; Chagpar et al., 2012; Fang et al., 2018; Jazieh et al., 2019; Shah et al., 2016; Visser et al., 2012)
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From page 85... ...
For example, an oncologist may recommend radiation therapy and refer a patient to a radiation oncologist but may not track whether the patient makes the appointment, initiates radiation treatment, or completes the recommended number of treatments. Local Therapies Surgery and radiation therapy are the two most commonly used local treatments for cancer.
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From page 86... ...
. Local Disease Cancer surgery is typically defined as the excision of the primary area of cancer and sometimes also the surrounding tissue or potential sites of regional metastasis, such as lymph nodes, blood vessels, nerves, and other adjacent organs.
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Reconstruction Cancer patients may require surgery to reconstruct anatomic defects or to address functional loss or disfigurement resulting from tumor resection or complications from cancer treatment. The most common reconstructive procedures are for breast cancer, head and neck cancer, extremity sarcomas, and skin cancers.
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From page 88... ...
to eradicate cancer cells. Radiation therapy acts directly or indirectly to damage the DNA of the cancer cells.
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From page 89... ...
Fractionation also allows normal cells to repair DNA damage and TABLE 4-6 Common EBRT Radiation Therapy Techniques Delivery Method Key Points 3-D conformal • Shape of the radiation beam conforms to the shape of the target radiation therapy • The shape of the beam is static at each angle (3DCRT) • A series of beams from different angles is used to deliver dose to the target and minimize dose to surrounding tissues • Most commonly used for whole-breast irradiation and palliative irradiation (see Chapter 5)
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From page 90... ...
Hyperfractionation is used for cancers that are known to proliferate rapidly, such as small-cell lung cancer, and for patients who need to go undergo re-irradiation to an area that had been irradiated in the past. The adverse effects of radiation therapy are generally classified as acute (those that happen during the course of radiation and last for several weeks to a few months)
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From page 91... ...
Minimally invasive tumor ablation should completely eradicate all the targeted tumor cells with minimal injury to surrounding tissues. Ablative techniques have been used to treat precancerous lesions or early-stage cancers with low risk of lymph node metastases since regional lymph nodes, which are a potential site of metastasis for more advanced cancers, are typically not treated. Ablation has also been used to treat metastatic lesions when a patient's prognosis may be poor and the morbidity that would accompany more extensive surgery should be avoided.
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From page 92... ...
The use of these therapies specifically for breast cancer, lung cancer, and selected other cancers is discussed in Chapters 5, 6, and 7, respectively. Chemotherapy Chemotherapy stops the growth of cancer cells, either by killing the cells or by stopping them from dividing; it is given in many different phases of cancer treatment.
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Carboplatin and paclitaxel Ovarian cancer Adjuvant and recurrent Cisplatin and pemetrexed Nonsquamous non-small- Adjuvant cell lung cancer with radiation (e.g., lymphoma or small-cell lung cancer)
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Examples include drugs such as trastuzumab, ado-trastuzumab emtansine, and pertuzumab, which target the HER2 oncogene; and gefitinib, erlotinib, afatinib, dacomitinib and osimertinib, which target the epidermal growth factor receptor (EGFR)
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From page 95... ...
. These immune checkpoint proteins are significantly improving survival and have been approved to treat a number of different cancers, including some types of breast cancer, non-small-cell lung cancer, and several other cancers; they are discussed in more detail in Chapter 8.
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From page 96... ...
Patients who survive several years after transplant continue to be at risk for significant late-onset effects in multiple organs, including bone disorders, cognitive dysfunction, new primary cancers, cardiac disease, pulmonary disease, chronic fatigue, and pain (Bhatia et al., 2017; Inamoto and Lee, 2017)
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From page 97... ...
Local recurrence means that the cancer has returned in the same location in which it was previously diagnosed -- for example, a breast cancer recurring after surgery within the residual breast tissue. Distant recurrence means that the cancer has returned in a new, distant location in the body, such as a brain cancer that occurs several months after the surgical removal of a primary lung cancer.
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From page 98... ...
Additionally, some cancer treatments can themselves cause cancer. Radiation therapy to the chest for patients with certain kinds of lymphoma can lead to the later development of cancers such as breast cancer (Dracham et al., 2018)
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From page 99... ...
. Targeted cancer screening for early detection of new primary cancers and additional risk counseling for young adult survivors (ages 20 to 39 years)
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6. Clinical practice guidelines developed by professional organizations such as ASCO and NCCN provide recommendations on standards of care for many kinds of cancer, including breast cancer and lung cancer.
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10. Systemic therapies include a number of standard-of-care agents such as chemotherapy, endocrine therapy, targeted therapy, immu notherapy, and stem cell therapy.
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2015. Impact of National Cancer Institute comprehensive cancer centers on ovarian cancer treatment and survival.
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2017. Recent advances in bronchoscopic treatment of peripheral lung cancers.
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2009. Quality of life supersedes the classic prognosticators for long-term survival in locally advanced non-small-cell lung cancer: An analysis of RTOG 9801.
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2019. Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening.
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From page 106... ...
2020b. Draft recommendation statement: Lung cancer: Screening.
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Key Terms
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