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CANCER TREATMENT MODALITIES PowerPoint Presentation

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Description : This presentation is intended to provide and introductory definitions about oncology and its related specialties.

Tags : Cancer, Oncology, Tumor

Published on : Nov 30, 2021 | Views : 3968 | Downloads : 16

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Oncology Basics CANCER TREATMENT MODALITIES Mohammed A. Suwaid, MD Board-certified Medical Oncologist Anbar Cancer Center
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AGENDA Cancer Oncology Role of MDT in managing cancer Surgical treatment Radiation treatment Systemic treatment
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WHAT IS CANCER Uncontrolled (abnormal excessive uncoordinated autonomous and purposeless) proliferation of cells. NEOPLASM CANCER Uncontrolled proliferation and spread within the body of abnormal forms of body's own cells.
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IS CANCER MANAGEABLE? IS CANCER CURABLE? The most significant 5 year survival is achieved in patients with skin, thyroid, cervix, uterus and bladder cancers. The worst survival is with pancreatic cancer. Females tend to have better numbers of 5 year survival than males, for ??
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ONCOLOGY Systemic Rx for solid tumors, hematological malignancies and HSCT. MEDICAL oncology CLINICAL oncology Systemic Rx for solid tumors RTH for solid and hematological malignancies SURGICAL oncology Surgical removal of cancer RADIATION oncology RTH for solid and hematological malignancies NUCLEAR medicine Radioactive substances ONCOS = TUMOR LOGOS = STUDY
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MULTIDISCIPLINARY TEAM TUMOR BOARD Integrated team approach to medical care in which cancer professionals consider all relevant treatment options and develop an individual treatment PLAN for each patient collaboratively Fighting the Crab – Kiev, Ukraine
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MULTIDISCIPLINARY TEAM MEDICAL oncologist CLINICAL oncologist SURGICAL oncologist RADIATION oncologist NUCLEAR physician PATHOLOGIST DIETICIAN RADIOLOGIST INTERNIST OTHERS Rehab., psych., etc. MDT
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CASE SCENARIO A 30-year-old lady presented to the GP with a breast lump associated with redness and ulceration of the overlying skin. He sent her for US which revealed a 5cm highly suspicious mass (BIRADS V) with few enlarged axillary LNs. FNAC revealed malignant cells. Which is the best option for managing this patient? A. Surgical removal of the mass and LNs. B. Radiotherapy to the breast and axilla. C. Chemotherapy plus hormonal treatment. D. Discussion within a context of MDT. BIRADS: Breast Imaging-Reporting and Data System
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CASE SCENARIO A. Surgical removal of the mass and LNs. B. Radiotherapy to the breast and axilla. C. Chemotherapy plus hormonal treatment. D. Discussion within a context of MDT. A 30-year-old lady presented to the GP with a breast lump associated with redness and ulceration of the overlying skin. He sent her for US which revealed a 5cm highly suspicious mass (BIRADS V) with few enlarged axillary LNs. FNAC revealed malignant cells. Which is the best option for managing this patient? BIRADS: Breast Imaging-Reporting and Data System
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TREATMENT MODALITIES Prophylactic treatment Treatment of establishes cases Surgery Radiotherapy Systemic therapy Within a context of MDT
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PROPHYLACTIC TREATMENT Surgical removal of a well known precancerous lesion. Examples: FAP  total proctocolectomy. BRCA-1/BRCA-2  bilateral mastectomy and prosthesis. FAP: Familial adenomatous polyposis BRCA: Breast cancer gene
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TREATMENT OF ESTABLISHED CASES Requires MDT Depends on tumor grading, staging and other factors. Two major categories (goals): Curative  early (locoregional) potentially operable disease. Surgery ± radiotherapy ± systemic therapy Palliative  late (metastatic) incurable and inoperable disease. Systemic Rx, usually no place for surgery or RTH (with exceptions).
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TREATMENT OF ESTABLISHED CASES Criteria of incurability: Distant metastasis(es)  most common Extensive locoregional disease with infiltration of adjacent organs Performance status Comorbidities
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SURGERY
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TYPES OF SURGERY Wide local excision e.g. early breast cancer, skin BCC Radical local excision e.g. Breast cancer + LN, CRC stage III Metastasectomy e.g. met CRC CURATIVE PALLIATIVE Symptomatic Rx QoL E.g. gastrojejunostomy, toilet mastectomy
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SURGERY A 50-year-old female referred to you from the GP with a recent history of anemia and +ve FoB. You requested colonoscopy which revealed polypoidal growth involving the sigmoid . Histopathology  Grade II adenocarcinoma. Imaging  -ve LN, -ve met. The patient has good PS and has no significant comorbidities. What is the best next step according to MDT discussion? Surgery Radiotherapy Chemotherapy Palliative treatment
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SURGERY A 50-year-old female referred to you from the GP with a recent history of anemia and +ve FoB. You requested colonoscopy which revealed polypoidal growth involving the sigmoid . Histopathology  Grade II adenocarcinoma with LVI. Imaging  +ve LN, -ve met. ~ 15 kg lost in the last 6mo, good PS, no significant comorbidities. What is the best next step according to MDT discussion? Surgery Radiotherapy Chemotherapy Palliative treatment
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RADIOTHERAPY
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RADIOTHERAPY Uses ionizing radiation to treat cancer Sources of IR: Natural: radioactive decay of Uranium, Plutonium, Cobalt, Radium, Iodide, etc. Man-made: LINAC system, Cyclotrons by sudden deceleration of high speed electrons when hitting a tungsten target Tungsten target implies an X-Ray tube where high energy electrons are directed in a vacuum to strike a tungsten target.
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BIOLOGICAL EFFECTS OF RTH RTH causes ionization in tissues This causes formation of free radicals FR interact and damage DNA Damaged DNA is unable to replicate during mitosis CELL DEATH
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ROLE OF RTH About 50 % of cancers will require RTH 2/3 of the cases uses RTH with curative intent H&N Cervix Anal Skin Prostate Bladder Early lung Early esophagus Seminoma HL & NHL Medulloblastomas and certain Brain tumors
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TYPES OF RTH INTERVENTIONS Pre-operative RTH Advantages: Downsize tumor Less mutilating Sx Sterilize SM Disadvantages: Clinical staging Overtreatment May ↑ Sx morbidity if radioresistant Ca
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TYPES OF RTH INTERVENTIONS Post-operative RTH Advantages: Pathological staging No overtreatment Disadvantages: Larger RTH field to cover the surgical bed Poorer blood supply  less effective ↑ late morbidity
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SYSTEMIC ANTI-CANCER TX Chemotherapy Targeted therapy Hormonal therapy Immunotherapy
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CHEMOTHERAPY Why term chemotherapy? Antimicrobial chemotherapy Some malignant cells can be cultured… Some malignancies can be transmitted by inoculation…
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CHEMOTHERAPY Is cancer chemotherapy as successful as antibiotic chemotherapy? NO Metabolism in bacteria differs qualitatively from host cells, while metabolism in cancer cells differ only quantitatively from normal host cells.
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CHEMOTHERAPY HENCE Target selectivity is more difficult in cancer Cancer cells do not cause a substantial immune response Diagnostic complexity  delay in institution of treatment
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CHEMOTHERAPY Guiding principles: Early diagnosis and early institution of treatment Total cell kill must be tried to achieve cure Combination chemotherapy Intermittent regimens Adjuvant and neoadjuvant chemotherapy
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EARLY DX AND EARLY TX Why? Survival time inversely related to initial number of cells Aging cancer cells are less susceptible to chemotherapy, because: ↑ cell cycle (division) time ↓ actively dividing cells with more resting cells Overcrowding of cells
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TOTAL CELL KILL Aimed at destroying all malignant cells leaving none. This approach ensures: Early recovery Prevent relapses Prolongs survival
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KINETIC BASIS OF DRUG THERAPY The objective of cancer treatment is to reduce the tumor cell population to zero cells. Fractional cell kill hypothesis states that a given drug concentration applied for a defined time period will kill a constant fraction of the cell population, independent of the absolute number of cells. Thus, each treatment cycle kills a specific fraction of the remaining cells. The results of treatment are a direct function of : (a) The dose of drug administered. (b) The number and frequency of repetition of treatment.
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TOTAL CELL KILL Aimed at destroying all malignant cells leaving none. This approach ensures: Early recovery Prevent relapses Prolongs survival
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COMBINATION CTH Heterogenicity of cells remaining in different phases of cell cycle, showing different levels of sensitivity Different biochemical sites of action Avoid emergence of drug resistance With rare exceptions, single drugs in standard doses do not cure cancer. Monotherapy is adequate in Burkitts lymphoma & choriocarcinoma
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INTERMITTENT REGIMENS Risk-benefit ratio Time for normal host cells to recover Kill cancer…save the patient…
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ADJUVANT & NEOADJUVANT Adjuvant chemotherapy: Chemotherapy given after surgery or irradiation to destroy micrometastasis & prevent development of secondary neoplasm. Neo-adjuvant chemotherapy: Chemotherapy given before surgery or radiotherapy in order to diminish the volume of large primary neoplasm
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INDIVIDUALIZING TREATMENT CHOICE Choice depends on: Histology, molecular and immunologic subtype, stage , and an additional factors, the patients probable tolerance for the side effects of various possible treatments. Severely debilitated patients and those with underlying medical problems, for example, renal failure, diabetes or chronic obstructive pulmonary disease might well suffer severely disabling or fatal complications from potentially curative regimens . When cure is not a realistic expectation, a decision to treat must be based on an expectation for prolongation of the patients life or an improvement in the quality of life. In these cases, treatment-related side effects may be minimized by dosage adjustments or treatment delays, when necessary, but at the cost of antitumor efficacy.
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CLASSIFICATION OF CYTOTOXICS
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GENERAL TOXICITY OF CYTOTOXIC DRUGS • Nausea & Vomiting • Bone marrow depression • Alopecia • Gonads: Oligospermia, impotence, ↓ ovulation • Fetus: Abortion, fetal death, teratogenicity • Carcinogenicity • Hyperuricemia • Immunosupression: Fludarabine • Hazards to staff
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SPECIFIC DRUG SIDE EFFECTS Cisplatin: nephrotoxicity Ifosfamide: hemorrhagic cystitis Fludarabine: immunosuppression Irinotecan: diarrhea Doxorubicin: cardiomyopathy Taxanes: SIADH Oxaliplatin: Neuropathy Bleomycin: pulmonary fibrosis
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TARGETED CANCER THERAPY DEFINITION Targeted drug is a drug that targets a specific molecule or pathway that plays a role in the growth and development of cancer rather than by simply interfering with all rapidly dividing cells. The goal of targeted drug therapy is to fight cancer with more precision and fewer side effects.
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TARGETED CANCER THERAPY CLASSIFICATION I. Monoclonal antibodies They are monospecific antibodies that target specific antigens found on the cell surface, such as transmembrane receptors or extracellular growth factors. This can lead to apoptosis, antibody-dependent cellular cytotoxicity, or complement-mediated cell lysis. Examples: Trastuzumab for the treatment of HER2/neu-positive breast cancer. Rituximab for the treatment of CD20+ B-cell NHL.
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II. Small molecules: Tyrosine kinase receptor inhibitors: EGFR inhibitor e.g. Gefitinib for treatment of non-small cell lung cancer. PDGFR inhibitor e.g. Imatinib for Ph+ CML & ALL and KIT+ GIST VEGFR inhibitor e.g. Sunitinib for treatment of renal cell carcinoma Proteasome inhibitors: e.g. Bortezomib for treatment of multiple myeloma. Cyclin-dependent kinase inhibitor: e.g. celiciclib which is now in multiple phase II studies for advanced NSCLC. TARGETED CANCER THERAPY CLASSIFICATION
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III. Gene Therapy Is a technique used for correction of defective genes responsible for cancer development by incorporating specific ribonucleotide sequences into them. This is accomplished by a number of ways such as: Antisense therapy (RNA). Viral vector transfection (RNA or DNA). DNA injection into tumors. Ex vivo transfection of selected tumor cells, immune cells, or bone marrow progenitors (DNA). TARGETED CANCER THERAPY CLASSIFICATION
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IV. Cancer vaccine Is a vaccine used to treat existing cancer or prevent the development of cancer in high-risk individuals by the use of tumor-specific antigens (and the immune response to them) for immune surveillance and tumor rejection. Several possibly effective cancer vaccines are currently in phase 3 trials. HPV vaccine for prevention of cervical cancer. TARGETED CANCER THERAPY CLASSIFICATION
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HORMONAL THERAPY DEFINITION AND TYPES Hormonal Therapy: Slow or stop the proliferation of cancer cells that are dependent on hormonal action to grow. Major types of hormonal therapy: Hormone-releasing factors Hormones Antihormones Selective Estrogen Receptor Modulators (SERM’s) Aromatase Inhibitors
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Thank You