Download An informative look at the Cancers you help diagnose

An informative look at the Cancers
you help diagnose
› Prior to 1953, what product was
advertised with the slogan,
“Just what the doctor ordered?”
Estimated
Deaths in 2015:
158,040 men and
women
- 221,200 New Cases
Diagnosed 2015
› 65 – 75% of diagnosed Lung Cancers are
INCURABLE at time of diagnosis
- HALF of those diagnosed will DIE within 1st
year of diagnosis
› Survival is based on Stage at time of diagnosis
- Overall 5 year Survival Rate for ALL Stages
of Lung Cancer is 15-18%
5 year survival rates
Lung – 17.8%
Colon – 65.4%
Breast – 90.5%
Prostate – 99.6%
Average age at diagnosis
– 70 y/o
- 2 of 3 are > 65 y/o
Only 2% diagnosed are
under 45 y/o
Age adjusted death rate
greater in men – (56.1 vs.
36.4/100,000)
Women on average 2
years younger than men
at time of diagnosis
90% OF DIAGNOSES
ATTRIBUTABLE TO SMOKING
OTHER CAUSES:
› Radon – accounts for 10%;
estimated 21,000 deaths/year
› Occupational Exposures - 9-15%,
includes Asbestos, Uranium and
Coke
>the combination of asbestos and
smoking greatly increases risk
>non-smoking asbestos workers are
5x more likely to develop lung cancer
› Outdoor Air Pollution – accounts for
1-2%
Up until a few
years ago,
people with lung
cancer were
relegated to the
coffin. We’re
going to bring this
under control.
- David Grant
(author)
› Lung Screening
- based on National Lung
Screen Trial findings
- Low Dose CT’s for 3
consecutive years
decreased the lung
cancer mortality be 20%
(with 5 year follow up)
- High Risk Population
only
› Other Diagnostic Tools
(some still in research
phase)
- Blood Tests
- Breath Tests
- Sputum Cytology
- Cell Sampling from
Airway via Bronchoscopy
› Targeted Therapies –
interferes with way
cancer cells function &
reduces damage to
normal cells
› Immunotherapies –
utilizes bodies own
immune system to fight
cancer
- A devastating disease usually
detected in an advanced incurable
stage
› 2015 Estimated New Cases – 16,980
MEN – 13,570
WOMEN – 3410
Accounts for 1% of all new Cancer cases
› 2015 Estimated Deaths – 15,590
MEN – 12,600
WOMEN – 2990
Accounts for 2.6% of all Cancer deaths
› 7th Most Common Cancer Death in Men
› Overall 5 year survival (all stages) – 18%
› Age: 45-75 years old at
highest risk
› Gender: Men>Women;
men 3-4 times more likely
to be diagnosed
› Race: Blacks 2x greater
than Whites to develop
Squamous Cell type
› Age 65 or greater
›
›
›
›
Male
Smoker
Heavy Alcohol use
Diet lacking fruits &
vegetables
› Obesity
› Acid Reflux
› Barrett’s Esophagus
› Achalasia – on average
Esophageal Cancer
diagnosed 15-20 years
after diagnosis of
achalasia
› Tylosis – rare dz, includes
small papillomas in
esophagus; high risk of
squamous cell cancer
› Plummer-Vinson Syndrome
– webbing of esophagus; 1
in 10 will develop
squamous cell carcinoma
› Difficulty/Pain with
Swallowing
› Pressure/Burning in Chest
› Indigestion/Heartburn
› Emesis
›
›
›
›
Choking on Food
Unexplained Weight Loss
Coughing, Hoarseness
Pain behind Sternum or in
Throat
Esophageal wall has
several layers
Knowing these layers
helps to understand how
these cancers start and
how they grow
Upper esophageal
sphincter – senses food
and opens allowing food
to pass
Lower esophageal
sphincter – allows food
into stomach; stops acid
reflux
› In United States, NO
regular screening tests in
asymptomatic patients
› Patients with known
Barrett’s Esophagus may
have regular endoscopic
evaluations to monitor
› Possible benefit of early
diagnosis in these
patients
› 54 y/o male present to
office with c/o chronic
indigestion with meals over
last 3 months.
› Additional symptoms
include change in appetite
secondary to discomfort,
occasional emesis, 15lb
weight loss over last 5-6
months
› PMH – Hypertension, recent treatment for Pneumonia
› PSH – unremarkable
› Social History – previous smoker, quit 1 year ago;
drinks 2-3 beers daily, sometimes more on weekends;
married & employed in HVAC services
› Family History – positive for gastric cancer in father
› Physical Exam - unremarkable
› Barium Swallow – aka
Upper GI Series
-shows abnormal areas of
normally smooth lining of
inner esophageal surface
- can also identify
complication known as
tracheo-esophageal
fistula
At this point
suspicion for
cancer is
very high!
› Stage of cancer
determines appropriate
treatment planning
› Multi-disciplinary work-up
- Medical Oncologist
- Radiation Oncologist
- Surgeon
- Gastroenterologist
› History & Physical – to
help detect gross
evidence of metastatic
disease
› CT chest/abdomen with
contrast to better
evaluate for disease
spread
› Bronchoscopy
- if airway involvement
suggested on CT studies
- all surgical candidates
should have airway
assessed prior to
treatment
› Better assessment of
primary tumor and depth
of invasion into
esophageal wall
› Assess for lymph node
involvement, distant
metastasis and other
structures outside of
esophagus
› Perform biopsies
› Includes:
- flexible bronchoscopy
- upper endoscopy
- diagnostic laparoscopy
peritoneal lavage
any indicated biopsies
Jejunostomy tube
› Stage “0” – high grade dysplasia, pre-cancer; close
follow up
› Stage I – grown into deeper layers of esophagus, no
lymph node involvement
T1 – surgery; chemo/radiation after if indicated
T2 – invades into mucosa propria; chemo/radiation
then surgery
* if near stomach, chemo only then surgery
* if upper portion of esophagus, chemo/rads, restage, if no signs residual disease, close follow up
› Stage II – grown into main muscle layer of esophagus
or into connective tissue outside; 1-2 nearby lymph
nodes may be involved
› Stage III – includes cancers that grown thru wall to
outer layer of esophagus as well as grown into nearby
organs or tissues; also includes spread to nearby
lymph nodes
*if patients are healthy, chemo/radiation then
surgical resection
*if Adenocarcinoma & near GE junction, chemo only
then surgery
› Stage IV – spread of disease to distant organs or
lymph nodes; usually only chemotherapy, other
treatments for palliation
> Radiation therapy for pain or trouble swallowing
> Dilation or Stent placement to help with strictures
> Laser Ablation of tumor (only temporary)
> Feeding Tubes
› Recurrence – local vs distant?
If local surgical resection; chemo +/- radiation
› Aimed at specific molecular targets found in tumor
that affect cell growth, angiogenesis, inflammation,
resistance to radiation and chemotherapies
› Have specifically found makers in esophageal
squamous carcinoma and adenocarcinoma near GE
junction > EGFR, HER2/Neu ( growth factor receptors)
> VEGF (angiogenesis)
> COX-2 (inflammation)
› HER2 +: Stage I > use Herceptin
(Ca near GE jxn,
Stage II > use Transtuzunab
no Rads)
-
Remove part or all of
esophagus
-
Create Neoesophagus utilizing
stomach
-
Lymph Node
dissection
-
Feeding Tube postoperatively
-
May be performed
using Robotic
Technique
As with most
malignancies,
complete accurate
staging, multidisciplinary
evaluation and the
use of standard
guidelines for stage
specific treatment is
critical in giving
esophageal and
lung cancer patients
the best outcomes.