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What is Staging?

Staging describes the extent orseverity of an individuals cancer

It is base on the extent of the

original (primary) tumor and theextent of spread in the body.


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Staging is important:

Staging helps the doctor plan a personstreatment.

The stage can be used to estimate the

persons prognosis (likely outcome orcourse of the disease).

Knowing the stage is important inidentifying clinical trials (researchstudies) that may be suitable for aparticular patient.


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Elements of Staging

Systems Location of the primary tumor

Tumor size and number of tumors,

Lymph node involvement

Cell type and tumor grade

Presence or absence of metastasis


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TNM System:

The TNM system is based on :

the extent of the tumor (T)

the extent of spread to the lymph nodes(N)

the presence of metastasis (M).

A number is added to each letter to indicatethe size or extent of the tumor and theextent of spread.


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Primary Tumor (T)

TX - Primary tumor cannot beevaluated

T0 No evidence of primary tumor Tis - Carcinoma in situ (early cancer

that has not spread to neighboringtissue)

T1, T2, T3, T4 - Size and/or extent ofthe primary tumor


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Regional Lymph nodes

NX - Regional lymph nodes cannotbe evaluated

N0 - No regional lymph nodeinvolvement (no cancer found in thelymph nodes)

N1, N2, N3 - Involvement of regionallymph nodes (number and/or extentof spread)


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Distant Metastasis (M)

MX - Distant metastasis cannot beevaluated

M0 - No distant metastasis (cancerhas not spread to other parts of thebody)

M1 - Distant metastasis (cancer hasspread to distant parts of the body)


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Examples:

breast cancer T3 N2 M0 It refers to a large tumor that has spread

outside the breast to nearby lymph nodes,

but not to other parts of the body. Prostate cancer T2 N0 M0

It means that the tumor is located only in theprostate and has not spread to the lymph

nodes or any other part of the body.


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Stage I ( T1, N0, MO)- Early Stage

Stage II (T2, N1, M0) local Spread

Stage III ( T3, N2, M0)- extensivespread but no metastasis.

Stage IV (T4, N3, M+) Advanced

stage, with distant metastasis


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5 Main Categories of

Cancer In situ is early cancer that is presentonly in the layer of cells in which itbegan.

Localized is cancer that is limited to theorgan in which it began, withoutevidence of spread.


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Regional is cancer that has spread

beyond the original (primary) site tonearby lymph nodes or organs andtissues.

Distant is cancer that has spread fromthe primary site to distant organs ordistant lymph nodes.

Unknown is used to describe cases for

which there is not enough information toindicate a stage.


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Stages of Cancer

Stage DefinitionStage 0 Carcinoma in situ (early cancer that is

present only in the layer of cells in

which it began).

Stage I, Stage II,

and Stage III

Higher numbers indicate more

extensive disease: greater tumor size,

and/or spread of the cancer to nearby

lymph nodes and/or organs adjacent tothe primary tumor.

Stage IV The cancer has spread to another

organ.


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Why Cancer Detection and

Testing Important?

Detecting cancers early is an important

step in preventing significant healthproblems.


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Four Possible Outcomes. True Positive

False Positive

True Negative False Negative


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When a test is performed to detect a

disease, there are four possibleoutcomes:

True positive - test indicates that a patienthas a disease that the patient does indeedhave

False positive - test indicates that a patienthas a disease when they do not


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True negative - test indicates the patientis disease-free, and this is indeed thecase

False negative - test indicates thepatient is healthy when in fact thepatient has the disease


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Sensitivity refers to how accurately a testidentifies people who have the disease.

Specificity refers to how accurately a testidentifies people who do not have the disease

The best medical tests have high sensitivity and

high specificity.


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Non - Invasive Invasive Techniques Analysis of Biopsy

Complete Blood Count(CBC)UltrasoundMRI

PET ScanCT Scan

Fine Needle AspirationCore Needle Biopsy

Immunohistochemistry(IHC)Fluorescent In SituHybridization (FISH)


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Ultrasound uses reflection of sound waves to

create an image of a part of the body

MRI uses magnetic fields and radio waves toproduce images of the body.

PET scans use radioactive molecules to create adynamic image of internal tissues and organs.PET scans are able to measure the metabolicactivity of cells, not just their structure.


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CT scans use x-rays to take multipleimage slices in order to create a 3Dimage.

X-rays utilized high energy beams tocreate an image.


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Non- Invasive: CBC

It provides information about the number,parts, shape, and structure of the differentcell types found in blood.

3 main types of blood cells: WBC

RBC

Platelets


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MRIWhen contrast agent is not

used an MRI can show:

When contrast agent is used

MRI can show:

contrast agent is not used an MRIcan show:

The shape, size, appearance, andlocation of organs, bones, andjointsThe presence of abnormal growthsSigns of inflammation or infection

size and location of benign ormalignant growths

enlarged lymph nodeschanges in blood flowextracellular volume


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Positron Emission

Tomography (PET) Is an imaging technique that uses radioactive

molecules to create a dynamic image ofinternal tissues and organs.

It produce images that reveal the activity ofliving tissue.

PET scans use radioactively labeled tracers(radiotracers) that are injected into the

bloodstream


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Computed Tomography

It uses x-rays in the same way as aconventional x-ray but instead oftaking one image a CT scanner takesmultiple images, or slices.

It can provide a 3 dimensional imageof an internal structure, it can detect

differences in tissue density.


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Fine Needle Aspiration (FNA) Core Needle Biopsy(CNB)


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Biopsy

Is the removal of cells, tissue, or fluidfor examination.


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Invasive Techniques

Fine needle aspiration (FNA) uses a

small needle to collect small samplesof a lesion.

Core needle biopsy (BPA) uses alarger needle to collect samples of alesion


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Fine Needle Aspiration Core Needle Biopsy

Sample Removed Removes only a very small portion of the lesion Removes a small portion in most

cases, occasionally removes the

entire lesionNeedle Size 22-27 gauge 11-18 gauge

Pathology Type Cytopathology Histopathology

Interpretation Time Immediately Delayed

Diagnostic Abilities Limited ability to specifically diagnose benign

lesions

No ability to differentiate between in situ and

invasive breast cancer

Strong ability to specifically

diagnose benign lesions.

Some ability to differentiate

between in situ and invasive breast

cancer.

Disadvantages Cannot be used for additional study More invasive, time consuming,

expensive

Advantages Inexpensive, quick, readily available, and very

safe

Can be used for additional study

and has more specific diagnosticabilities than FNA

Effectiveness Sensitivity: 75.8-98.7%

Specificity: 60-100%

Positive Predictive Value: 93.5-100%

Sensitivity: 91-99.6%%

Specificity: 98-100%

Positive Predictive Value: 10


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Analysis of FNA

Benign - the mass is not of much concern and willnot cause any significant problems as long as itremains unchanged.

Atypically indeterminate - a diagnosis cannot beobtained from the sample. Other tests are neededto determine the nature of the lesion.

Suspicious/probably malignant- not a diagnosis ofcancer. This type of diagnosis requires additional

investigation because the sample has abnormalcharacteristics. This lesion should be biopsiedwith a more complete method to determinewhether a malignancy (cancer) is present.


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Malignant- a diagnosis of cancer;should be biopsied and tested for exacttumor makeup to prepare for

treatment. Unsatisfactory- a diagnosis cannot be

determined from the sample because

of insufficient sample size, processingor other machine or human errors.


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Examination of TissueSamples Immunohistochemistry (IHC)

Fluorescence in SituHybridization (FISH)


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Immunohistochemistry (IHC)

Is a technique used to determine thepresence and level of specific cellularproteins.

An example: Three proteins of particularinterest in breast cancer are HER2, theestrogen receptor (ER) and the progesterone

receptor (PR).


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Fluorescence in SituHybridization (FISH)

Is a cytogenetic technique used to detectand localize the presence or absence of

specific DNA sequences on chromosomes.

FISH uses fluorescent probes that bind toonly those parts of the chromosome with

which they show a high degree of sequencesimilarity.


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Cancer Specific Techniques

Mammography uses low dose x-rayto create an image of a breast.

Sigmoidoscopy uses a small tubecontaining viewing equipment toview the colon.

Virtual Colonoscopy uses an MRI or

CT scan to create an image of theinside of the colon.


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Pap smears use a sample of cells from thecervix to detect cervical cancer. Pap smearsmay also detect ovarian and uterine cancers

that have migrated to the cervix.

Prostate specific antigen (PSA) testmeasures levels of a glycoprotein in the

blood. Elevated levels of PSA are associatedwith prostate cancer


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Sentinel Lymph Node

Biopsy (SLN) is used to detect metastasis.


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THANK YOU!


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Treatment Goal

Is to cure the client eradicate thetumor.

When cure is not possible, controllingor arresting a tumor growth becomesthe goal to prolong the survival.

Palliation or alleviation of symptoms.


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Treatments

Surgery

Radiation Therapy

Hormonal Therapy

Targeted Therapy Antibodies

Cancer Vaccines

Complimentary and AlternativeMedicines

Chemotherapy


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Surgery

The first line of treatment for manysolid tumors.

May be sufficient to cure the patientby removing all cancerous cells.

Surgery is often used in combinationwith radiation and/or chemotherapy


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Types of Treatment

Local Excision- simple surgery with smallmargin of normal tissue surrounding tumor.

En bloc Dissection- removal of tumor, tissues,and any contiguous structures.


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Surgery on Cancer in Situ

Electrosurgery- application ofelectrical current to cancerous cells

Cryosurgery- deep freezing withliquid nitrogen

Chemosurgery- appliedchemotherapeutic agents layer by

layer with surgical incision. Co2 laser- use of laser for laser

excision.


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Radiation

May be used in conjunction withsurgery and/or drug treatments.

The goal of radiation is to kill thecancer cells directly by damagingthem with high energy beams


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Radiation Therapy

Radiation treatments utilize high-energywaves to kill cancer cells.

Use of high energy moving throughspace or medium to treat disease.

It can be used alone or in conjunctionwith other treatments (e.g.chemotherapy and surgery) to cure orstabilize cancer.


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Objectives:

This treatment seeks to relievesymptoms of the cancer and toprolong survival, making life more

comfortable.


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Indications

Used to treat tumors- ionizingradiation transfers energy tomolecules present in cancer cells.

Different tissues have different radiosensitivities rapidly dividing tissues

(testes, ovaries, lymphoid tissues,and bone marrows) are moresensitive.


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Types of Radiation

Electromagnetic- radiation in wave form

Xrays- linear accelerators

Electrons- delivered by machines

Gamma- rays delivered by machines thatcontain radioactive sources (Cobalt 60), orradioactive substances ( seeds, threads)

Particulate radiation in the form of heavy

particles. (beta particles- High speedelectrons)


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Postoperative Radiation

It can destroy cancer cells stillpresent around the margins after atumor has been surgically removed.


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Internal Radiation

Is the process of implantingradioactive material onto or near thetumor or placing radioactive sources

into the body.

Implantation of radioactivesubstance within a client.

It can be temporary or permanent. Also called brachytherapy


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Types of Internal

Radiation Unsealed sources: Isotopes Liquid and administered orally.

Sealed Sources: Radium needles andradon seeds. Radioactive substance encased in metal

capsule placed in body cavity.

Delivers radiation directly to tumor


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External Radiation

It utilizes a machine to deliver radiationto the tumor.

This therapy is primarily an outpatient

treatment. Most protocols last approximately 4-7

weeks with treatments given 5 days perweek

Also called as Teletherapy- externalsource of radiation. ( machine is adistance from client)


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2 Types of External

Radiation Natural Radioactive Source - gammarays delivered via machine to lesion.

Machine is the linear accelerator-high voltage electric current deliverselectrons to client.


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Photon Radiation

It uses high energy rays composed ofparticles of energy called photons.

Photon radiation acts by disrupting the molecules of the target cells, interfering with normal cell functions.There are several types of photon radiation:

Gamma rays: are produced by thebreakdown of radioactive isotopes ofelements such as Cobalt-60 andradium

X-rays: originate from machines thatexcite electrons using cathode raytubes or linear accelerators.


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Administration of RadiationTherapy Internal

Seed implants Brachytherapy

External External Beam Radiation Therapy

3-D Conformal Therapy and IntensityModulated Radiation Therapy (IMRT)


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Benefits

Destroys quickly dividing cells at themargins of tumors. Surgery may miss thesecells leading to recurrence of disease.

Can successfully eradicate growth without

permanently damaging the adjacent normaltissue. If these tumors can be treated early beforemetastasis, there is a very high rate of curability.

In conjunction with other treatments, may

cure tumors that are not responsive to anysingle agent.


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Hormonal Treatments

It prevent cancer cell growth bypreventing the cells from receivingsignals necessary for their continued

growth and division


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Targeted Therapy

They work by targeting specificproteins and processes that arelimited primarily to cancer cells or

that are much more prevalent incancer cells.

Inhibition of these processes

prevents cancer cell growth anddivision.


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Antibodies

This treatment involves the use ofantibodies to target cancer cells.

The antibodies may work by several

different mechanisms, either depriving thecancer cells of necessary signals or causingthe direct death of the cells.

Because of their specificity, antibodies may

be thought of as a type of specific inhibitor.


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Biological Response

Modifiers These treatments involve the use ofnaturally occurring, normal, proteinsto stimulate the body's own defenses

against cancer.


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Cancer Vaccines

It stimulate the body's defensesagainst cancer.

The treatment aims to increase theresponse of the body against thecancer cells.

Vaccines usually contain proteins found onor produced by cancer cells. Byadministering these proteins,


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Chemotherapy

It refers to a wide range of drugsused to treat cancer.

These drugs generally work by killingdividing cells.


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Goal of Chemotherapy

Is to cure malignancy

Control maybe the goal when cure isnot realistic; the aim is to extendsurvival and improve the quality oflife.

Palliation may be the goal when

neither cure nor control maybeachieved; this goal is directed towardclient comfort.


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Types of Chemotherapy

Drugs Antimetabolites Genotoxic Drugs

Spindle Inhibitors Other Chemotherapy Agents


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Anti- Metabolites

Drugs that interfere with theformation of key bio-moleculeswithin the cell including nucleotides,

the building blocks of DNA. These drugs ultimately interfere with

DNA replication and therefore cell

division.


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Types of Anti-

metabolites Folate Antagonists

Purine Antagonists

Pyrimidine Antagonists


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Folate Antagonist

also known as antifolates

It inhibit dihydrofolate reductase (DHFR),an enzyme involved in the formation of

nucleotides. When this enzyme is blocked,

nucleotides are not formed, disruptingDNA replication and cell division

Methotrexate and Pemetrexed


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Pyrimidine Antagonists act to block the synthesis of pyrimidinecontaining nucleotides (C and T in DNA; Cand U in RNA).

The drugs used to block the construction ofthese nucleotide have structures that are

similar to the natural compound. By acting as 'decoys', these drugs can

prevent the production of the finishednucleotides. They may exert their effects at

different steps in that pathway and maydirectly inhibit crucial enzymes.


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5-fluorouracil

Arabinosylcytosine

Capecitabine Gemcitabine

Decitabine

G t i D


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Genotoxic Drugs

Drugs that damage DNA. By causingDNA damage, these agents interferewith DNA replication, and cell

division 3 Treatments:

Alkylating Agents

Intercalating Agents Enzyme Inhibitors


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The genotoxic chemotherapytreatments include:Alkylating agents: The first class of chemotherapy

agents used. These drugs modify thebases of DNA, interfering with DNAreplication and transcription andleading to mutations


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Intercalating agents

These drugs wedge themselves into the

spaces between the nucleotides in theDNA double helix. They interfere withtranscription, replication and inducemutations.

Enzyme inhibitors

These drugs inhibit key enzymes, such as

topoisomerases, involved in DNAreplication inducing DNA damage.

S i dl I hibit


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Spindle Inhibitors

These agents prevent proper celldivision by interfering with thecytoskeletal components that enable

one cell to divide into two.

Vinca AlkaloidsPaclitaxel (Taxol)Docetaxel (Taxotere)Ixabepilone (Ixempra)


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Additional Chemotherapy

Agents While many of the commonly used

chemotherapy agents fit into one of thethree previously described groupings(Genotoxic, Cytoskeletal, and Anti-metabolite), some of them work throughmechanisms that do not neatly fit into one ofthese categories.

Arsenic trioxide (Trisenox)

BleomycinHydroxyureaStreptozocin

Ch th ti


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Chemotherapeutic

Administration Oral IM/ SQ

IV

Central Venous Catheter

Venous Access Devices (VAD)

Intraarterial Route Intraperitoneal Route

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