The Big C An Introduction to Cancer Therapy

Nicholas James @Prof_Nick_James #NJCancerlecture

Introduction What is cancer? How is cancer caused? How common is cancer? How is cancer treated?

What is cancer?
Cancer is a disease of cells Cells are the building blocks of the body Cells work together to make organs, kidney, heart, liver etc. or blood

Cells can multiply by cell division

......like a human population.. cell division is needed for,

Growth

Healing

Replacing old cells

In order to fulfil these functions cells need to multiply very fast..

In the past minute your body has made 300 million new red blood cells 12,000 million new intestinal cells 40,000 new skin cells

Cancer is..
An uncontrolled growth of cells. That is of no use and Acts like a parasite Has the ability to grow & spread and destroy other body parts metastasis

A bit of terminology
Oncology - study of cancer Lit. the study of lumps or masses Neoplasm - a new growth - one that shouldnt be there Malignant neoplasm - a tumour which, if untreated, causes death = a CANCER Benign neoplasm - a tumour which doesnt usually cause death Tumour - usually means a neoplasm Lit. any swelling

Terminology of cancer
Cancers can be, Primary
- From the organ in which the cancer starts - Cancers are named after the primary

Secondary
- In the organ to which the cancer spreads - Also known as a metastasis - Generally maintain the characteristics of the primary

What do cancers look like? Primary Lung Cancer

Normal lung

A lung cancer

What do cancers look like? Primary cancer of the bowel

What do cancers look like? Primary Liver cancer

What Do Secondary Cancers Look Like?

Lung from bone

Brain from lung

Liver from colon

Liver from pancreas

Bone cancer spread from prostate

How do metastases develop?

Primary Tumor

Tumor cell Invasion

Transportation to another organ

Disseminated cells Microscopic metastases

Tumorigenesis

Metastasis

Clinically Significant Secondary Tumors that cause pain and fractures

Development of overt metastases

HOW IS CANCER CAUSED?

What causes cells to multiply out of control?

Damage to a cells genetic material - DNA
There is a fault in the instructions Cells multiply too quickly accelerator on or break off Cell dont die when they should Cells dont move on & dont differentiate into the next stage of their life

Cancer Development

Carcinogenesis
Damage to the DNA to start the process

Angiogenesis
To grow beyond 1-2 mm, the tumour needs to initiate the recruitment of its own blood vessels

The major causes of cancer How do the genes get damaged ?

Acquired (what you get during life) Chemical - as in tobacco smoke & alcohol Radiation - background, atomic bomb, medical Infections viruses and other infectious agents usually a long latent period, then a pre-clinical stage, and then overt cancer Germline (what you're born with) e.g. some forms of breast cancer

HOW COMMON IS CANCER?

The global perspective

World Population New cancer cases Cancer deaths % in developing 2000 6bn 10m 6m 50% 2020 8bn 20m 12m 70%

countries

Cancer Incidence and Mortality UK

Mortality Incidence

In the UK death from cancer is plummeting in the young and middle aged

Tobacco control Screening and early diagnosis Better treatment

The UK leads the world in tobacco control - and reaps the benefits
The UK led the research that identified smoking as a cause of cancer The UK started to control it before anyone else

Smoking & cancer - good news

Smoking & cancer - bad news

Worldwide - 10% of women, 50% of men smoke About 4 m people die from tobacco each year By 2020 the number will be 10 m One third of all deaths in China will be caused by smoking tobacco Increasing smoking in adolescent girls and boys & in developing countries

In the UK death from cancer is plummeting in the young and middle aged

Tobacco control Screening and early diagnosis Better treatment

What cancers are we screening for ?

Breast cancer currently under review Cervical cancer Colon Cancer Prostate cancer not at present, though test exists

In the UK death from cancer is plummeting in the young and middle aged!

Tobacco control Screening and early diagnosis Better treatment

Mortality Rate From Breast Cancer US and the UK

Progress in testicular cancer

Can you vaccinate against cancer?

No, but you can vaccinate against some of the causes

Hepatitis B
2 billion people infected 25% of infected adults will get liver cancer Vaccination against hep B is causing rapid falls in liver cancer rates

Human papillomavirus
Specific types linked to cervical cancer Vaccine now available to girls Should we vaccinate boys as well?

HOW IS CANCER TREATED?

Treatment of cancer Diagnosis Staging Treatment Follow up

Cancer Diagnosis
Cancers are diagnosed by:

History & Clinical examination Imaging e.g. X-rays or CT scanning Less often, blood tests Tissue biopsy and histological assessment

Patients arrive by different pathways

Symptoms

May be specific to one cancer e.g. enlarged lymph nodes May be non-specific e.g. weight loss, anorexia
Screened

A test given to a person with no symptoms of a disease e.g. Cervical smears, colonoscopies, PSA tests and mammograms
Incidental

Picked up whilst investigating another symptom

Major presenting symptoms Lung Cancer

Patients (%) 100 80 60 40 20 0
Shortness of breath Cough Pain Loss of appetite Coughing up blood

Baseline major presenting symptoms Hollen et al 1999

Cancer Diagnosis

Cancers are diagnosed by:

History & Clinical examination Imaging e.g. X-rays or CT scanning Less often, blood tests Tissue biopsy and histological assessment

Diagnosis - imaging

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Cancer Diagnosis
Cancers are diagnosed by:

History & Clinical examination Imaging e.g. X-rays or CT scanning Less often, blood tests Tissue biopsy and histological assessment

Tissue biopsy getting some of the cancer for microscopic analysis the definitive diagnostic step
Core Fine needle Surgical
Percutaneous or Via a scope.. Colonoscopy, bronchoscopy Cystoscopy etc

Staging of lung cancer

Lymph nodes

Invasion of chest wall Metastasis to distant organs Main bronchus Stage 0 Stage IA Stage IIB Stage IIIB Stage IV

Contralateral lymph node

5-year survival by TNM status in lung cancer

Stage IA IB IIA IIB IIIA IIIB IV TNM classification T1N0M0 T2N0M0 T1N1M0 T2N1M0 or T3N0M0 T1-3N2M0 orT3N1M0 T4NanyM0 or TanyN3M0 TanyNanyM1 5-year survival (%) 61 38 34 24 13 5 1

Mountain 1997

Treatment Of Cancer
Surgery Radiotherapy Drug treatments
- Chemotherapy - Hormone therapy - New drug classes

Surgery bladder cancer

Radiotherapy

Chemotherapy
As sole therapy
- leukaemia

As part of package of care

- Breast cancer - Bowel cancer

For palliation
- Lung cancer - Prostate cancer

Side effects of chemotherapy

Mucositis Alopecia

Pulmonary fibrosis Nausea/vomiting Diarrhea Cystitis Sterility Myalgia Neuropathy Cardiotoxicity Local reaction Renal failure Myelosuppression Phlebitis

New directions in cancer therapy

Robot assisted surgery

Three dimensional planning

Image guided radiotherapy

Cyberknife

Targeted molecular therapies

Sorafenib

Oral therapy Targets the tumour and its blood supply

TARGETs Patient 251-050

21 June 2005

17 October 2005

Palliative care
Adding life to days when we cant add days to life

Active therapy

Palliative care Time

Diagnosis

Death

Cancer Is A Disease Of Genes.but

Its effects are all too human A diagnosis of cancer affects the patient but also friends and family Holistic care of patient & family are key features of good cancer care

Palliative care is multifaceted..

Skilled symptomatic treatment Pain, nausea and vomiting Breaking bad news Simple straight forward information Sympathetic listening Leaving patient in control of his own life for as long as possible

ANY QUESTIONS?