Oncology Medical Management

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Introduction

Oncology is a branch of medicine that deals with tumors.

  • A medical professional who practices oncology is an oncologist.
  • Tumours simply refer to the mass.
  • Cancer is a particularly threatening type of tumor that refers to new growth and has the ability to invade surrounding tissues, metastasize (spread to other organs), and which may eventually lead to the patient's death if untreated.
  • Another term in oncology is Neoplasm which is an abnormal new growth of cells. The cells in a neoplasm usually grow more rapidly than normal cells and will continue to grow if not treated. As they grow, they may impinge or damage adjacent tissues. A neoplasm can be classified as a benign tumor (localized and does not metastasized) and malignant tumors (cancerous and metastasized).
  • Cancer can be defined as a malignant neoplasm.[1] Cancer is a chronic disease which if untreated is progressive in nature.[2]

Oncology examination is necessary to screen the patient initial state and later to determine the patient's prognosis.

  • History taking is an important screening tool: the character of the complaints and nonspecific symptoms (such as fatigue, weight loss, unexplained anemia, fever of unknown origin, Paraneoplastic phenomena, and other signs) may warrant further investigation for malignancy.
  • A physical examination may help localize a malignancy.
  • The radiographic finding helps to find the location, size of the neoplasm.
  • Diagnostic methods include: Biopsy or Resection; these are methods by which suspicious neoplastic growths can be removed in part or in whole, and evaluated by a pathologist to determine malignancy. This is currently the gold standard for the diagnosis of cancer and is crucial in guiding the next step in management[3]

Multidisciplinary treatment approach

Cancer is managed in a multidisciplinary team setting to improve outcomes (quality of life and prolong the person's life) of the patient and decrease the morbidity.

The multidisciplinary team includes the following members: surgeons, radiation, and medical oncologists/hematologists, palliative care physicians, radiologists, pathologists, general practitioners, nurses, and allied health professionals (Occupational therapist, Physiotherapist).[2]

There are various roles specified to each multidisciplinary team members. For instance,

Specialties Examples of roles
Medical oncologist Chemotherapy, biological therapy, hormonal therapy
Radiation oncologist External beam radiotherapy, brachytherapy, systemic radiation
Palliative care Symptom control, hospice care
Oncological surgeons Definitive and palliative surgery
Allied health:

Dietician, physiotherapy, occupational therapy, social work, pharmacy and psychology

Relevant to each speciality
Cancer nurses Care coordination, clinical trials, chemotherapy administration[2]

Aim of Cancer treatment

The aims of treatment are broadly classified into:

Curative/Radical treatment:

The main aim of this treatment is to get a cure for cancer completely. Primary treatment can be supported by neoadjuvant or adjuvant treatment.

For curable cancers, the rate of cure is determined by prognostic factors (for example tumor size and nodal status in breast cancer).

Palliative treatment:

The goals for palliative treatment is to prolong survival and improve quality of life by controlling symptoms. In most of the cases, concurrent use of palliative care and active anti-cancer therapy is necessary to maintain quality of life. In these situations, it is important to identify and treat the cause of the symptoms rather than adopting a 'one size fits all' management plan.[2]

For instances,

  • Pain: simple analgesics, narcotics, parenteral narcotic
  • Nausea: metoclopramide, 5HT3 antagonist, steroids
  • Loss of appetite: steroids
  • Cough/SOB: codeine, narcotics, nebulizers.
  • Depression: control symptoms, correct causes, counseling, antidepressants family support, aids, home visits, physiotherapy, nutrition, occupational therapy, social work[2]

For incurable cancers, the rate of survival is expressed in medial survival rather than in absolute time frame which is determined by previous large databases.[2]

[4]

Principle of cancer management

The principle of cancer management help to set the goal of the treatment for the patient and thus determine the prognostic factors of the patient[2]. The overall approaches to cancer management depend on the following considerations:

Tumor factors

It includes:

  • Type of cancer
  • Stage of cancer/Extent of the spread of cancer.
  • Curable VS Incurable cancer[2].

Treatment factors

It refers:

  • Whether a treatment is actually available
  • How likely it is to work and
  • Whether it is likely to produce significant side effects.

Patient factors

It is the most important factor. It concerns:

  • Whether the patient is fit enough to have a treatment and
  • Their personal preferences as to whether they want a treatment or not.
  • Any other preexisting co-morbidities

ECOG performance status

It stands for Eastern Cooperative Oncology Group performance status. It is an assessment tool that helps to assess the functional status of a patient before and after treatment for cancer. It is a 6 graded scale which helps to determine patient functional status and thus help to choose the treatment option for the patient.

Types of cancer management

There are various cancer management approaches that are determined based on the principle of cancer management. Most people with cancer have a combination of treatments eg: surgery with chemotherapy and/or radiation therapy. All these treatments can be used as curative, adjuvant (to eliminate mico metastatic disease after primary treatment), palliative (to improve symptoms) based on considerations for principle for cancer management.[2]

[5]

Cancer management can be broadly divided into the following types:

Medical therapies

Medical oncology communicates the results of clinical and experimental research in oncology and hematology, particularly with experimental therapeutics with the field of immunotherapy and chemotherapy. Thus any therapeutic procedure which is related to the blood or given through the blood route for cancer treatment is known as medical therapy. It includes the following treatment.

Immunotherapy

It is a type of biological therapy that helps the immune system to act better against cancerous cells. Immune cells are sometimes found in and around tumors cells, which are called tumor-infiltrating lymphocytes or TILs, and are signs that the immune system is responding to the tumor. It is not common as Surgery, chemotherapy and radiation therapy.

There are various types of Immunotherapy. Some of them are:

  • Immune checkpoints inhibitor.
  • T-cell transfer therapy.
  • Monoclonal antibodies.
  • Treatment vaccines.
  • Immune system modulators.

Common side effects of immunotherapy include skin changes (rashes, itchiness, sore, redness), swelling, pain, flu-like symptoms, etc.[6]

[7]

Chemotherapy

In this treatment, drugs are used to kill or slow the growth of the cancerous cells. It can be used as curative or palliative care or as neoadjuvant (making a tumor smaller before surgery or radiation therapy).

There are many different chemotherapy drugs which one to include in treatment plan depends on:

  • The type of cancer you have and how advanced it is
  • Whether you have had chemotherapy before
  • Whether you have other health problems, such as diabetes or heart disease

Chemotherapy can be given via various routes. Some of them are: oral, intravenous, intrathecal, intraperitoneal, intra-arterial, intramuscular, topical.

For chemotherapy, patients can visit the OPD of respective hospitals. Treatment schedules for chemotherapy vary widely. How often and how long one can get chemotherapy depends on:

  • Type of cancer and how advanced it is
  • Whether chemotherapy is used to:
    • Cure your cancer
    • Control its growth
    • Ease symptoms
  • The type of chemotherapy one is getting
  • How your body responds to the chemotherapy

Chemotherapy can be received in a cycle. A cycle is a period of chemotherapy treatment followed by a period of rest. [8] Damage to healthy cells may cause side effects. Side effects may go away after the completion of chemotherapy. Some of the common side effects are soreness of mouth, fatigue, nausea, and hair loss.

[9]

Hormonal therapy/ Endocrine therapy

Hormone therapy is a cancer treatment that slows or stops the growth of cancer that uses hormones to grow. It can be used to treat cancer or ease the symptoms. Hormone therapy falls into two broad groups, those that block the body’s ability to produce hormones and those that interfere with how hormones behave in the body. Hormonal therapy can be mainly given through oral, injections, or surgery ( removing organ producing hormone). It is mostly used in breast and prostate cancer.[10]

[11]

Targeted therapy

Targeted therapy is the foundation of precision medicine. It is a type of cancer treatment in which a drug is given based on the genetic nature of cancerous cells. It targets proteins that control how cancer cells grow, divide, and spread. [12]

Stem cell transplant

Stem cell transplants are procedures that restore blood-forming stem cells in people who have had theirs destroyed by the very high doses of chemotherapy or radiation therapy that are used to treat certain cancers. they directly don't help to treat cancer but help to form the blood-forming stem cells which fight against cancer cells.

The blood-forming stem cells that are used in transplants can come from the bone marrow, bloodstream, or umbilical cord. Transplants can be autologous, allogeneic, and syngeneic. Stem cell transplants are most often used to help people with leukemia and lymphoma. They may also be used for neuroblastoma and multiple myeloma.[13]

[14]

Surgery

It is the procedure performed minimally invasive or open to remove primary cancer and lymph nodes and for palliation by removing the mass causing symptoms.[12] There are various ways through which surgery can be performed such as cryosurgery, laser, etc. For instance mastectomy or lumpectomy in breast cancer.

Radiation therapy

In this therapy, a high dose of radiation is used to kill the cancerous cell or to shrink the cancerous cell so that it will be easier to remove it via surgery or to kill the remaining cancerous cells. At high doses, radiation therapy kills cancer cells or slows their growth by damaging their DNA which doesn't allow them to multiple and die. It takes days or weeks of treatment before DNA is damaged enough for cancer cells to die. It can be used as a curative, adjunct, or palliative care.

There are two types of radiation therapy:

  1. External beam: External beam radiation therapy is a local treatment, which means it treats a specific part of your body. it does not touch your body but move around you, sending radiation to a part of the body from many directions. For example, if you have cancer in your lung, you will have radiation only to your chest, not to your whole body.
  2. Internal radiation therapy: It is a treatment in which a source of radiation is put inside your body. The radiation source can be solid or liquid. Internal radiation therapy with a solid source is called brachytherapy. Brachytherapy is like external beam therapy as it is also a local treatment in which seeds, ribbons, or capsules that contain radiation sources are placed near or in a tumor. Brachytherapy is most often used to treat cancers of the head and neck, breast, cervix, prostate, and eye. Internal Radiation Therapy with the liquid source is called systemic therapy that travels in the blood to tissues throughout the body and kills cancerous cells. It can be given via swallowing, through a vein via IV line or through an injection. A systemic radiation therapy called radioactive iodine, or I-131, is most often used to treat certain types of thyroid cancer. Another type of systemic radiation therapy called targeted radionuclide therapy is used to treat some patients who have advanced prostate cancer or gastroenteropancreatic neuroendocrine tumor (GEP-NET). This type of treatment may also be referred to as molecular radiotherapy.[12]
[15]

Lifetime doses limit of Radiation

There is limited quantity of radiation that our body can cope up with during our lifetime period. Beyond that exposure of radiation, that part of our body should not be exposed to radiation.

Side effects of Radiation therapy

Radiation not only kills or slows the growth of cancer cells, but it can also affect nearby healthy cells which cause side effects. The side effects of radiation therapy vary based on the site of treatment. The common side effects of radiation therapy are:

  • Fatigue ( which may affect working capacity and hours.)
  • Hair loss
  • Skin changes
  • Nausea and vomiting[16]

Oncological Emergencies

Oncological emergencies are a group of conditions that may occur as a direct or indirect result of cancer and are potentially life-threatening.

Physical Therapists need to be aware that certain oncologic emergencies may develop over time and it is important to know the primary systems affected or causes as well as signs and symptoms for referral[17]. They are broadly divided into metabolic, hematological, structural or side effects of chemotherapy agents.

I. Metabolic

  1. Tumor Lysis Syndrome
  2. Hypercalcemia of Malignancy
  3. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

II. Hematologic

  1. Febrile neutropenia
  2. Hyperviscosity syndrome

III. Structural

  1. Epidural Spinal Cord Compression
  2. Malignant Pericardial Effusion
  3. Superior Vena Cava Syndrome

IV. Side Effects from Chemotherapy

  1. Extravasations injuries
  2. Gstrointenstinal complaints. eg dehydration, obstipation

References

  1. (1) The Sol Goldman Pancreatic Cancer Research Center and Johns Hopkins Medicine Pathology. What are tumors? Available from: http://pathology.jhu.edu/pc/BasicTypes1.php [July 07 2020].
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 (2) Sabe S, Dewar J, Wyld D and Cancer Council Australia Oncology Education Committee. Cancer Council Australia. Clinical Oncology for students. Principle of oncology management. Available from: https://wiki.cancer.org.au/oncologyformedicalstudents/Principles_of_cancer_management [July 07, 2020].
  3. (3) Medical Oncology. Available from: https://www.omicsonline.org/medical-oncology-journals-conferences-list.php [July 07, 2020].
  4. learn oncology. General Principles of Cancer Treatment. Available from: https://www.youtube.com/watch?v=64tUb6B0jSU[last accessed 7/13/2020]
  5. Oncology for Medical Students. Principles of Cancer Treatment. Available from: https://www.youtube.com/watch?v=dK_4JvYnBMg[last accessed 7/13/2020]
  6. National Cancer Institute. Immunotherapy to treat cancer. Available from: https://www.cancer.gov/about-cancer/treatment/types/immunotherapy [July 09, 2020]
  7. National Cancer Institute. Immunotherapy: How the Immune System Fights Cancer. Available from:https://www.youtube.com/watch?v=jDdL2bMQXfE [last accessed 7/13/2020]
  8. National Cancer Institute. Chemotherapy to treat cancer. Available from: https://www.cancer.gov/about-cancer/treatment/types/chemotherapy [July 09, 2020]
  9. Nucleus Medical Media. Cancer Treatment: Chemotherapy. Available from:https://www.youtube.com/watch?v=vKIRWY-LMYc [last accessed 7/13/2020]
  10. National Cancer Institute. Hormone therapy to treat. Available from: https://www.cancer.gov/about-cancer/treatment/types/hormone-therapy [July 09, 2020]
  11. Breast Cancer Answers. Understanding the Basics of Hormone Therapy. Available from:https://www.youtube.com/watch?v=o94weqCkOv4 [last accessed 7/13/2020]
  12. 12.0 12.1 12.2 National Cancer Institute. Treatment for Cancer. Available from: https://www.cancer.gov/about-cancer/treatment [July 09, 2020]
  13. National Cancer Institute. Stem cell transplant to treat cancer. Available from: https://www.cancer.gov/about-cancer/treatment/types/stem-cell-transplant. [Last accessed: July 13, 2020]
  14. MD Anderson Cancer Center. What you should know about stem cell transplants. Available from:https://www.youtube.com/watch?v=u-_Uke5oLGg [last accessed 7/13/2020]
  15. Learn Oncology. How Radiotherapy Works! Available from:https://www.youtube.com/watch?v=ZgAi4wQLqZ0 [last accessed 7/13/2020]
  16. National Cancer Institute. Radiation therapy side effects. Available from:https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/side-effects [July 13, 2020]
  17. Higdon M et. al. Treatment of Oncologic Emergencies. Am Fam Physician 2006; 74: 1873-80