Oncology Medical Management

Original Editor - Elaine Lonnemann

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This article is currently under review and may not be up to date. Please come back soon to see the finished work! (13/07/2020)

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Introduction

Oncology is a branch of medicine that deals with tumors. A medical professional who practices oncology is an oncologist. Tumors simply refer to the mass. Whereas 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 also defined as a malignant neoplasm. Thus, Cancer is a chronic disease which if untreated is progressive in nature.

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

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).

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

Principle of cancer management

The overall approach to cancer management depends on the following considerations:

1. Type of cancer.
2. Stage of cancer/Extent of the spread of cancer.
3. Curable VS Incurable cancer.

These considerations help to set the goal of the treatment for the patient and thus determine the prognostic factors of patient.

Curable cancer:

The goals for curable cancer could be: curative care (active anti-cancer therapy, surgery)

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

Incurable cancer:

The goals for incurable cancer is to prolong survival and improve quality of life. It may include palliative care (the aim of palliative care is to 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.

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

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.

Types of cancer management

There are various cancer management approaches which 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 treatmenst can be used as curative, adjuvant (to eliminate micr metastatic disease after primary treatment), palliative (to improve symptoms) based on considerations for principle for cancer management.

Cancer management can be broadly divided into 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.

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 route. Some of them are: oral, intravenous, intrathecal, intraperitoneal, intra-arterial,intra-muscular, topical.

for chemotherapy, patients can visit to 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.

Side effects

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.

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. 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, 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 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 contains radiation source are placed near or in tumor. Brachytherapy is most often used to treat cancers of the head and neck, breast, cervix, prostate, and eye. Internal Radiation Therapy with 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. <section> </section><section> </section>

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 causes 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

Oncological Emergencies

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. The study suggests using a multidisciplinary treatment system for early diagnosis (MRI) and referral to orthopedists for treatment and prevention of Malignant spinal cord compression (MSCC) in patients with bone metastases.

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. Diarrhea
2. Extravasations
3. Obstipation