BASIC PRINCIPLES OF MEDICAL

ONCOLOGY
 In 2002, 5.8 million new cases of cancer in
developing countries.
By 2020 however, it is predicted 15-20 million new
cases of cancer.
The burden of cancer in developing countries is
growing and threatens to exact a heavy morbidity,
mortality and economic cost in the next 20 years.

WHO cancer priorities in developing countries

Annals Oncol 17 ( supplement8): vii9-vii14, 2006
 LEADING CAUSES OF MORTALITY (%) INDONESIA

CAUSES 1992 1995 2001

DISEASE OFCIRCULATORY SYSTEM 16.0 18.9 26.4
RESPIRATORY INFECTIONS 9.5 15.7 12.7
DIGESTIVE DISEASES 5.1 6.6 11.3
TUBERCULOSIS 11.0 9.6 9.4
NEOPLASM 4.0 5.0 6.0
CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD 5.2 4.9
DIARRHEA 8.0 7.4 3.8
INFECTIOUS AND PARASITIC DISEASES 7.8 7.9 7.7
ENDOCRINE AND METABOLIC DISEASES 2.7
OTHERS 38.6 23.7 15.1

Source Ministry of Health, National Health Survey; 1992, 1995, 2001 Official Publications
CANCER MANAGEMENT: A MULTIDISCIPLINARY
APPROACH
A TEAM OF A HEALTH CARE PROFESIONALS WITH
EXPERIENCE IN TREATING CANCER

Surgeon (i.e Oncology, Digestive, Thoraco s, Urologist)

MEDICAL ONCOLOGIST
Radiation Oncologist
Pathologist, Radiologist
Oncology Nurse, Social Worker
Others
CANCER DIAGNOSIS
WORK-UP
 DIAGNOSIS WORK UP:
(Breast Cancer as a Model)

HISTORY: SYMPTOMS & FACTORS RELATED

PHYSICAL EXAMINATION: GENERAL & LOCAL
IMAGING: MAMMOGRAM, ULTRASOUND, MRI
BIOPSY: FNA, CORE
TISSUE EXAMINATION AND PATHOLOGY REPORT
 OTHER TESTS AFTER CANCER HAS BEEN DIAGNOSED

TO MAKE SURE THAT CANCER HAS NOT SPREAD TO DISTANCE

ORGANS
CHEST X RAY
CT SCANS
MRI
POSITRON EMISSION TOMOGRAPHY (PET) SCANS
LABORATORY TESTS
TUMOR TESTS: ESTROGEN RESEPTOR (ER), PROGESTERONE
RESEPTOR (PR), HER-2/neu
 DEFINING THE EXTENT OF THE DISEASE AND
THE PROGNOSIS
STAGING

CLINICAL STAGING: based on PE and imaging

PATHOLOGIC STAGING: included information

obtained during surgical procedure, inspection and
biopsy of organs commonly involved in the disease
spread
 DEFINING THE EXTENT OF THE DISEASE AND THE
PROGNOSIS

Staging:
TNM system ( T=Tumor; N=Node; M=Metastasis)
The International Union Against Cancer and AJCC:
American Joint Committee on Cancer
Dukes classification: Colon cancer
FIGO: International Federation of Gynecologists and
and Obstetricians
Ann Arbor classification for Hodgkins disease
Primary tumor (T)
TX: primary tumor cannot be evaluated
T0: no evidence of primary tumor
Tis: carcinoma in situ
Regional lymph nodes (N)
Nx: regional lymph nodes cannot be evaluated
N0: no regional lymph node involvement
N1, N2, N3: involvement of regional lymph nodes (number and/or extent of
spread
Distant metastasis (M)
Mx: distant metastasis cannot be evaluated
M0: No distant metastasis
M1: distant metastasis
 BREAST CANCER % LUNG CANCER %
(8-YEAR SURVIVAL) 5-YEAR SURVIVAL
I 90 I 47

II 70 II 36

III 40 III 8

IV 10 IV 2
TREATMENT PLAN
 CANCER CHANGES EVERYTHING:

PHYSICAL WELL-BEING: TREATMENTS, SIDE EFFECTS,

DOCTORS VISITS, TESTS
PSYCHOSOCIAL ASPECTS: SELF IMAGE, WORK, FAMILY
 TREATMENT APPROACH BASED ON INFORMATION
FROM:

EXTENT OF THE DISEASE (STAGE)

PERFORMANCE STATUS
AGE
PROGNOSIS
PATIENTS WISHES
PS FUNCTIONAL CAPACITY OF THE PATIENT
100 NORMAL (N)
90 N, minor signs and symptoms
80 N effort, some signs and symptoms
70 CARES FOR SELF, UNABLE TO CARRY ON (N) ACTIVITY
60 Requires occasional assistance, able to care for most needs
50 Requires considerable assistance and frequent medical care
40 Disabled, requires special care and assistance
30 Severely disabled, hospitalization is indicated
20 Very sick, hospitalization necessary, active supportive
treatment is necessary
10 Moribund, fatal processes progressing rapidly
0 DEAD
 THE GOAL OF TREATMENT:

CURATIVE
PALLIATIVE
 SURGERY (LOCAL)
RADIATION THERAPY (LOCAL)
CHEMOTHERAPY (SYSTEMIC)
HORMONE THERAPY (SYSTEMIC)
MOLECULARLY TARGETED THERAPIES (SYSTEMIC)
TREATMENT OF SYMPTOMS
COMPLEMENTARY & ALTERNATIVE THERAPIES
 ALL (PEDIATRIC PATIENTS)
AML (ADULT)
LMH
LMNH
TESTICULAR TUMOR (GERM CELL CA)
CHORIO CARCINOMA
 EXTERNAL BEAM RADIATION

INTERNAL RADIATION
Stadium I,II Terapi bedah Lokal
Kemoterapi, ajuvan Medik , sistemik
Radioterapi, ajuvan Lokal
Hormon, ajuvan Medik, sistemik

Stadium III Kemoterapi (neoajuvan) Medik, sistemik

Terapi bedah Lokal
Kemoterapi (ajuvan) Medik, sistemik
Radiasi ajuvan Lokal
Hormon, ajuvan sistemik
Stadium IV Kemoterapi (Paliatif) Medik, sistemik
Radiasi (Paliatif) Lokal
Hormon Medik, sistemik
 DOXORUBICIN
CYCLOPHOSPHAMIDE
EPIRUBICIN
VINORELBINE
PACLITAXEL (TAXOL, PAXUS)
DOCETAXEL (TAXOTERE)
CAPECITABINE (XELODA)
GEMCITABINE (GEMZAR)
 TAMOXIFEN
ANASTROZOLE (ARIMIDEX)
EXEMESTANE (AROMASIN)
LETROZOLE (FEMARA)
BORTEZOMIB PROTEASOME MYELOMA M.
INHIBITORS
BEVACIZUMAB VASCULAR BREAST AND
ENDOTHELIAL COLORECTAL CA.
GROWTH
FACTOR
ERLOTINIB EPIDERMAL GFR NSCLC
IMATINIB TIROSINE KINASE CML
INHIBITOR
RITUXIMAB MONOCLONAL LMNH
ANTIBODIES
 Complementary
Medicine is used along
with standard medical
treatments.
Acupuncture to help with
side effects of cancer
treatment.
 Alternative medicine is
used in place
of standard medical
treatments
Special diet instead
treatment that an
oncologist suggest.
DIETARY SUPLEMENTS AND HERBAL PRODUCTS
MEDITATION, TAI CHI, REIKI, MASSAGE
 Here some important facts about dietary
supplements:

Herbal supplements may be harmful: kava (for stress

and anxiety), may cause liver damage.
Too much of any vitamin is not safe, even in a healthy
person.
 COMPLETE RESPONSE
PARTIAL RESPONSE
PROGRESSIVE DISEASE
STABLE DISEASE
 TUMOR MARKERS ARE NOT SPECIFIC ENOUGH TO
MAKE DIAGNOSIS OF MALIGNANCY

TUMOR MARKER CAN BE USED TO ASSES RESPONSE

TO TREATMENT
 TUMOR MARKERS CANCER NON-NEOPLASTIC
CONDITION

CEA Ca Colon, Lung, Pancreatitis,

(Carcino Embryonic Antigen) Pancreas, Breast, Hepatitis, IBD,
Ovary Smoking

Ca-125 Ovarian Cancer, Menstruation,

Lymphoma Pregnancy, Peritonitis

AFP Hepatocellular Cirrhosis, Hepatitis

Carcinoma, Gonadal
(Alfa Feto Protein)
Germ cell tumor
 TUMOR MARKERS CANCER NON-NEOPLASTIC
CONDITION

LDH Lymphoma, Ewings Hepatitis, Hemolytic

(Lactate Dehydrogenase)
Sarcoma anemia

PSA Prostate Cancer Prostatitis, Prostatic

(Prostate Specific Antigen) hypertrophy
 TREATMENT
COMPLICATIONS
Bone marrow suppression Nausea and Vomiting

Hair loss Constipation

Loss of appetite and body Diarrhea

weight
Taste changes Fatigue

Stomatitis and esophagitis Cardiotoxic

Neuropathy
 MOUTH PROBLEMS

DRY MOUTH
A LOT OF CAVITIES
LOSS OF TASTE
SORE MOUTH AND GUMS
INFECTIONS
JAW STIFFNESS
JAW BONE CHANGES
 KEEP MOUTH MOIST
DRINK A LOT WATER
SUCK ICE CHIPS
SUGARLESS GUM
SALIVA SUBSTITUTE

CLEAN MOUTH, TONGUE,

GUMS
USE SPECIAL FLUORIDE
FLOSS TEETH GENTLY
 LATE COMPLICATIONS

If the patient has disease-free, the patient is followed

regularly for disease recurrence:
Monthly for 6-12 months
Every other month for 1 year
Every 3 months for a year
Every 4 months for a year
Every 6 months for a year
Annually
Could be to cure sometimes

To extend life often, and

To comfort always
The End