IMI Health Hour - Introduction to Cancer

1. IMI Health Hour - Introduction to Cancer Dr Shane Zaidi Consultant Clinical Oncologist Sarcoma Unit, The Royal Marsden Hospital & The Institute of Cancer Research, London.

2. Intro • The very word cancer is a loaded or charged term and diagnosis will completely change outlook as perception incurable and reminds us of death. • Identify cancer with disease and treatment related side effects losing weight, being sick losing hair, and until recently very poor outcomes. • Taboo subject in many cultures/societies • 1 in 2 people will suffer some form of cancer in their lifetime. • A leading cause of death ( 2nd to CVS disease) and suffering • Try to give an overview of this topic define terminology, follow up in the future more specific topics.

3. History of Cancer • Not a new illness • Described by ancient civilizations • Egyptians- evidence bone cancer mummified bodies and described and rudimentary forms of cancer surgery • Greek for Karkinos (Crab) 400 BC by Hippocrates- father medicine • Parallel crab- hard tumours- like a crab’s shell or painful from the claw? • Major advances in understanding, diagnosis treatment in the last 100 years (modern surgery/RT and chemo). • We now have a better understanding of how normal cells behave and hence how cancers can cause changes in the building blocks of life or the DNA and the genes • Combined with advanced laboratory techniques last 20 years better understand of what it is, how it develops and new treatments. • Led to new more advanced treatments and trying to change to a chronic illness.

4. What is Cancer? • The basic building block is called a cell • We now understand that Cancer starts when these cells behave in an abnormal uncontrolled manner and start to copy or divide and can forms growths called tumours. • The primary cancer refers to where the cancer starts . If the cancer spreads to another site then this is called a secondary or a metastatic cancer.

5. Benign and Malignant Tumours • Tumours are growths • a lump can either be benign or malignant Benign tumours grow slowly, don’t spread and have normal cells.  They can grow large, cause problems -press on body organs/nerves, vessels or inside the skull take space or release chemicals called hormones. Malignant tumours are made up of cancer cells Grow quickly, can spead into surrounding tissue or spread other areas- SERIOUS

6. What causes cancer-Risk factors • Patients ask- why me?don’t always have an answer BUT. • Smoking ( 1/3)- PREVENTABLE • Diet • Environmental exposure - • Sun and UV • Chemicals • radiation • Viruses • Hereditary?

7. Is Cancer a genetic disease? • Humans have around 25,000 genes and these are instructions telling a cell what to do. • Inherited 50% from mother and father. • Within the body -Define things like hair and eye colour, height, basic level what type of body cell develops and when to grow and when to die • These genes can pick up mistakes when they are made or repaired and can cause what we call is an error / fault or mutation. • Things that can cause mutations include natural cell processes and other things like smoking, radiation, UV sunlight, chemicals in the environment and food . • So you could argue that all cancers are by definition a genetic disease but this does not mean they are passed on from parent to child or inherited. • Most cancers start due to changes taken place over the persons lifetime but rarely, cancers can be inherited due to faulty genes passed down to families.

8. Cancer Type • Represents many different conditions • >200 types • Broadly speaking groups into • Carcinoma ( organs-lungs colon etc  skin), brain tumours, sarcomas and also blood-lymphomas and leukaemias.

9. How cancer grows • Once grow to a certain size they breakthrough barriers and spread. • Rely on the blood supply to get food and oxygen • Form new cancer blood vessels to deliver the nutrition • Cancers tend to grow along easiest path avoiding difficult routes like bone, cartilage.

10. How cancer can spread? • Primary cancer- where it started • Secondary or metastatic cancers- cancer spread from the primary. • How? Use the body’s bloodstream and lymph system. • Common sites include liver, lungs, lymph nodes bone and brain. • We know that certain cancers have a tendancy or behaviour to spread specficorgans- colon cancer- liver, lung-liver/bone/brain. Breast- nodes/liver lungs etc.

11. Stages cancer-universal language • concept that helps us to treat cancers as it describes how far the cancer has grown. • Important because helps the team to decide how best to treat that particular patient. • Use whole body scans (CT, MRI, PET, Bone scan) • If a cancer is in 1 place- better chance of using a local treatment like surgery or RT to try to kill it completely. • If a cancer has spread then need to use a treatment that goes around the whole body like chemotherapy etc. • Different systems used • Common system is stage 1-4 • 1 –denotes small local cancer. • 4 -means spread outside from the primary cancer

12. Cancer tests • Is this cancer?Biopsy- • Need to confirm this is a cancer and other features looking for specific changes. • How big and where? • CT MRI/CT-PET • In preparation for treatment • Blood tests check the normal body function( bone marrow, liver and kidney function) • Tumour markers in some cancers- non-specific.

13. Cancer Grading • To make a diagnosis need to get some of the tissue from where the suspected cancer is using a biopsy • Doctors also talk about grading cancers • This describes how abnormal the cells are in relation to the normal cells when looking under a microscope • Will help to predict how the cancer behaves (coming back original site or spreading). • Use a system 1-3 • 1=Low grade tumours may grow more slowly.  • 3=High grade tumours grow quickly and more likely to spread.

14. Cancer and the body • What does cancer do to the body? • Cancer can stop the body’s normal functions either directly or due to treatment side effects • Cancers can stop normal function either by direct effect ( pressing on an organ such as the lung, liver) or though releasing chemicals • We think that cancer is a disease of the immune system not being able to get rid of the abnormal cancer cells. • Cancer is also thought to affect the immune system and can weaken it.

15. Cancer symptoms • Related to where the cancer is • Related to loss function or pressure etc • Local (cough, SOB,bowel habit, croaky voice, dysphagia, heartburn) • Lump( breast, elsewhere) • New skin lesions- mole • Persistent Pain (tissue, nerves) • Bleeding ( blood vessels)- haemoptysis, PR, GI, PV • General- appetite,Weightloss,night sweats

16. Who gets cancer? • Anybody can suffer with cancer • This can depend on things like • Age • Risk generally increases with age. 60% after retirement 65 years. • But children and young adults (different from adults) • Gender • Slightly more men than women • Ethnic origin ( western/eastern) • Geography

17. Common cancers • Lung • Breast /prostate • Bowel • Oesophagus • ovary/pancreas • Lymphoma • Melanoma • NHL • Others: • Renal • Head and neck • Brain/bladder • Leuk • Uterus • Gastric • Liver • Myeloma • Thyroid • Cervix

18. Urgent Cancer referrals • Triggered by new symptoms • 2 weeks in the UK through GP or primary care • Some patients may have delay in diagnosis • Streamlined pathway for accessing specialists

19. Cancer treatments • Depend on type cancer/stage/grade • Important understand • Curative – remove whole cancer using • Combination surgery /RT /chemo • Palliative-cannot remove cancer (large/critical organs or metastatic) not cure but control. Well possible long as possible and QoL.

20. MDT/tumour board • This is a team of health professionals who work together to decide on which is the best treatment and care . • Essential collective experience evidence to improves outcomes and pat experience • Discourage independent lone practice. • Tumour board AHP discuss all new cases in an attempt to standardise practice and complex discussions.  • Evidence based and Minimisehealth inequality • Expert review in that field • Surgical, cancer specialist chemo/RT, radiologist, pathology, CNS, dietician, palliative care team, nurses, pharmacy, plastics..long list • If not directly seen then link up via conference calls • Not always performed- data suggest this may negatively impact on patient’s chance cure/control.

21. Surgery • Main curative treatment • Aim to remove the primary tumour . ( +/- 1-2 mets in selected cancers mCRC) • Margin of normal tissue called a margin • New techniques developed • Improving the pre and post patient care • Evidence that the complex surgery should be performed experienced high volume centre. • Main problems- select patients carefully • A good surgeon also knows when Not to perform unnecessary surgery. A tumour may be operable, but patient factors may not allow resection anaesthetic risk. Etc. • Rare tumours should not be managed in a low volume centre-

22. Radiotherapy • 50% patients receive RT at some point • Strong x-rays- External or internal • Curative-before/after on instead surgery • Palliative- improve QoL- pain, bleeding cough • bone, lung, pelvis, spine to • Side effects as RT cannot tell difference between cancer and non-cancerous tissue • Deliver treatment over several weeks ( 5-6) or shorter if palliative 1-12/15 • Alone or in combination with chemo

23. chemotherapy • Strong drugs used to try and  kill cancer cells  • Used in a curative settting before or after surgery or RT- alone some cancers • Curative in a few cancers germ cell tumours, lymphoma and childhood cancers • palliative in most cancers- try to control cancer/shrink • Hormones- suppress effects in breast and other cancers like prostate ( tablets/patches/implants) • Biological agents that target specific abnormalities present in cancer but not normal cells- personalised targeted therapies. Magic bullet Gleevac (2001). multiple new drugs.  Main issue is the cost and side effects. Usually given until stop working.

24. chemotherapy • As outpatient or inpatient via drip (lines portacath/HL PICC) or – fear of needles and rpt bloods • Tablets • Course chemo- 6-8 sessions-varies drug/administered • Cycles 21-28 days- allow body to recover in between dose- cancer cells are not good at repair • Side effects because drugs can't tell difference between rapidly normal or cancer rapidly dividing cells-  • SIDE EFFECTS- sickness, fatigue, bone marrrow(anemia, infections) kidney/heart etc. • Fertilty and chemo

25. Managing Symptoms and Side effects • Due to cancer or treatment • Team approach • Proactive- not reactive medicine • Nausea+vomiting • Pain • SOB • Constipation • infections • Clots

26. New drug treatments-biologicals • Work on specific processes in cells- targeted therapy • Stop growing or dividing • Immune system • Immunotherapy- boost body immune system to fight cancer- vaccines and other drugs • Monoclonal Abs • Cancer growth factors blockers • Blocking new blood vessel formation • Gene therapy

27. How do we know if the treatment is working? • Radical or curative setting • Clinical examination +CT scans ( blood tests) after surgery to check local/systemic relapse • Palliative setting • Symptoms and signs ,scans ( reply on size other ways too how active tumour is) 2-3 cycles and bloods

28. Why do some cancers can come back? • Patients/relatives and healthcare staff are always concerned about this • Not all the cells are removed or treated with surgery/RT or chemo • They may have spread and not show up on the scans • CT scan 1cm • May need extra treatment like hormones or chemo to mopp these cells up • Resistant to treatment like antibiotics and recurrent infections. • Cure versus remission • Uncertainty

29. Clinical trials? • Trying to develop new treatments to improve the cure and control of cancer  (drug/surgical or RT technique) • Usually new drugs are developed in the lab and tested on animals like mice • Need to test in humans for safety and then whether they work • If they do work then compare with the current standard treatment • Lots of clinical trials in cancer medicine and a trias is testing new treatment/technology/tests. Not a guarantee it will work or be better. IMPORTANT TO REALISE this.

30. Cancer screening • Screening programmes developed in an attempt to improve survival by detecting asymptomatic cases earlier thereby hoping better outcomes. • Breast • Bowel • Cervical • Not for all cancers several reasons: • Need a reliable test that finds cancers in people who have it without unnecessarily worrying healthy people • Be safe • Cost-effective • Prostate/lung/ovarian?

31. Coping with Cancer • Fear unknown+ Leaving loved ones behind • Team approach- CNS to Support • Psychological and Spiritual support • Physio/OT/welfare • Work -financial concerns • Holidays+ Insurance • Our current healthcare platform not designed to support patients during this • Little time during consultations • LISTEN TO YOUR PATIENTS…

32. New Advances • New drugs agents • Targeted treatments • Immunotherapy and cancer • New surgical techniques • Da vinci robot • New RT techniques • Using SBRT/Cyberknife higher doses where surgery not possible? Same result? • Treating stage 4 cancer aggressively

33. Death and dying • Despite all research at some point sometimes the treatments don’t work and need to focus on stopping things • Difficult decision -Not giving up • Taboo subject • Difficult and depends on patients and family etc • Planning ahead • wills/living wills/CPR etc. complex discussions to have with medical/healtcare team • Support at home/ hospice etc

34. Palliative Care • Symptom control team • More interesting at dealing with specific complaints like pain, breathlessness, etc rather than chemo/RT/surgery. • Important at all stages of the cancer journey • Not doom and gloom and used in non-cancer setting • Experts in using the correct medication for a problem. • Work with specialists • Linked to hospice

35. Survivorship • Better at treating patients • Lag behind at supporting patients long term survivors • Problems due to cancer/treatment etc • Living the fear that may recur • Organ function/fertility/risk second cancers/relationships/taboo/social network etc • ‘Scanxiety’-3 monthly blocks • Support groups • Patient directed follow up and support • Integrating digital platform

36. Cancer statistics • Commonly used by healthcare to help us to understand how people do with cancer, comparing different treatments • Tells us how many new cases diagnosed, how many people are living with cancer, how people do after treatments, how many people die from cancer. • Apply to a population of people but cannot identify who in that group will be affected. • Do not tell us what will happen to you as a patient.

37. Cancer statistics and Prognosis • Discuss 1, 2 and 5 year survival rates • Also talk about the average lifespan • Depends on cancer type, stage, grade and other factors

38. Conclusions • Cancer is a spectrum of conditions • Early diagnosis and treatment • Lots new treatments • Chronic condition • Prevention • Smoking 1/3 cases world wide • Obesity • Diet+lifestyle • Viruses 20%

39. The 20 Most Common Causes of Cancer Deaths: 2003-2005 and 2012-2014 Percentage Change in European Age-Standardised Mortality Rates per 100,000 Population, Males, UK Source: cruk.org/cancerstats You are welcome to reuse this Cancer Research UK statistics content for your own work. Credit us as authors by referencing Cancer Research UK as the primary source. Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].

40. The 20 Most Common Causes of Cancer Deaths: 2003-2005 and 2012-2014 Percentage Change in European Age-Standardised Mortality Rates per 100,000 Population, Females, UK Source: cruk.org/cancerstats You are welcome to reuse this Cancer Research UK statistics content for your own work. Credit us as authors by referencing Cancer Research UK as the primary source. Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].