Download Solid Tumors

Solid Tumors
Anthony W. Stephens, M.D.
2015
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Cancer
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Characteristics
– abnormal cell growth
– spread/metastasis
Incidence (U.S)
– 1.6 million/year
– 600,000 deaths (1500 / day)
– 77% of all cancers in age >55
Survival approximately 67% at 5 years
– Was 49% in the 1970’s
2nd leading cause of death in the US
Accounts for 1 of every 4 deaths
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Breast Cancer
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Most common cancer in U.S. women
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Second leading cause of cancer deaths
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1 out of 8 women affected in their lifetime
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can also affect men (1%)
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Slight decrease in incidence from 19992006 by 2%/year
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Breast Cancer
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Scope
– 232,000 cases/year
– 40,000 deaths/year
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Incidence highest in North America and
Europe, lowest in Asia and Africa
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Mortality declining by 2.5% since 1990’s
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2.9 million survivors living in U.S. today
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Breast Ca: Etiology
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Risk factors:
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family history/genetics
Increasing age/gender
hormonal factors
diet/lifestyle (obesity/inactivity)
Weight gain after age 18
Radiation exposure
alcohol intake (>1/day)
high breast density
High bone mineral density
LCIS in either breast
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Breast Ca: Etiology
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Hormonal Factors
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Early menarche
Late menopause
Nulliparity
1st pregnancy> 30 years
Menopausal hormone therapy (MHT)
Protective Factors
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Breastfeeding
Avoid weight gain
Limit alcohol
Exercise
Tamoxifen / Raloxifene
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Types of Breast Cancer
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Ductal
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Lobular
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In situ vs. Invasive
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Less common (mucinous, tubular,
metaplastic)
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Inflammatory (1-2%)
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Very aggressive, red/swollen/inflamed
Paget’s disease
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Breast Cancer: Genetics
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Positive family history in 15-20% of
patients (most patients do not have a
family history)
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Do not neglect paternal family history
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RR:
– one 1st degree = 1.8
– two 1st degree = 3
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Only 5-10% of breast cancer are due to
specific mutation (e.g. BRCA 1 or 2)
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Breast Ca: Etiology
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Genetics: BRCA 1 mutation
– Accounts for 5% of breast CA
– chromosome 17 short arm
– characteristics:
 early age, bilateral disease
 autosomal dominant
 cumulative risk
 ovarian cancer
 high penetrance
BRCA 2 mutation
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Autosomal dominant
Men may be carriers
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BRCA Testing
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Criteria
Counseling
 Psychosocial effects
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Interventions / Prophylactic Surgery
(mastectomy, oophorectomy, drugs,
more aggressive screening)
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Breast Ca: Presentation
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Usually asymptomatic (mammogram)
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Palpable, painless lump- most benign
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Thickening, dimpling, erythema, nipple
retraction or discharge, bleeding, or
persistent pain
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Role of mammogram, u/s, biopsy, MRI
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Only 5% present with metastases
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Breast Ca: Screening
Mammography
Reduce mortality by > than 25%
 ACS recommendations: yearly
beginning at age 40
 US Preventive Services Task Force
recommendations (controversial)
 Increase discovery of early stage ca
 False negative rate of 10-15%
 Does not substitute for biopsy
 Risk of false positive result
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Breast Ca: Screening
Monthly self breast exam
 Annual physician exam
 Role of genetic testing
 Ultrasound – breast density
 MRI
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– High risk women (e.g. BRCA)
– In addition to mammography
– Expensive, higher false positive rate
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Breast Ca: Treatment
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Surgery - lumpectomy vs. mastectomy
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Sentinel node biopsy
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Adjuvant chemotherapy/radiation
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Hormonal therapy: Tamoxifen, Aromatase
inhibitors (e.g. Arimidex, Femara)
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Targeted Therapies (Herceptin, Tykerb,
Perjeta)
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Breast Ca: Prognosis
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Five year survival: 84-98% for
localized/regional disease
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Five year survival: 24% for metastatic disease
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Factors: size, lymph node involvement, grade,
hormone receptors, Her2Neu, molecular /gene
expression
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Risk of late relapse
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Lung Cancer: Facts
Incidence:
 Second most common in both sexes
 Leading cause of cancer deaths in males
and females
 226,000/ year diagnosed in US
 160,000 deaths/year in US
 Declining incidence in males > females
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Lung Cancer: Facts
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Survival
– 43% at 1 year
– 16% at 5 years
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Accounts for 14% of cancer diagnoses,
28% of cancer deaths
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Small advances in recent years
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Lung Ca: Etiology
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Tobacco use causes 80% of cases
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Risk increases with pack years
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Occupational / Second hand exposure
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Associated Ca’s: larynx, oral cavity, pharynx,
esophagus, bladder, cervix, pancreas
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Other RF’s: age, asbestos, radon
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RR 20-30 in smokers
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Some genetic susceptibility
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Lung Cancer: Type
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Adenocarcinoma = 35-45%
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Squamous Cell = 20-30%
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Large Cell = 10%
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Small Cell = 15%
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Lung Ca: Presentation
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Few “early” symptoms
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Persistent cough, pneumonia, hoarseness, hemoptysis,
dyspnea, chest pain, bone pain, weight loss
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Abnormal chest x-ray (10% of patients)
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Paraneoplastic Syndromes (e.g. Ca++, SIADH, clubbing)
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Lung Ca: Screening
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Chest x-ray, sputum cytology
– No benefit
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Chest CT , sputum molecular markers
– Low dose, spiral CT reduced mortality by 20%
in heavy smokers
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Lung Ca: Diagnosis
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Abnormal chest x-ray
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Chest/abdomen CT scan
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Bronchoscopy/ biopsy
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Staging (e.g.: head CT, bone scan)
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PET scan
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Lung Ca: Treatment
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Defined by type and stage
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Surgical resection, if feasible
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Radiation/chemotherapy
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Survival
– Dependent on Stage, health of patient
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Targeted therapy (e.g. Tarceva, Avastin, Xalkori)
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Lung Ca: Treatment
DON’T SMOKE!
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Prostate Ca: Facts
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Most common cancer in U.S. males (240,000/year)
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One of six US males
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Incidence higher in African Americans
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Mortality rates have been declining since 1990’s
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Second leading cause of cancer death in men
(29,000/year)
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Prostate Ca: Risk Factors
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Associated with advanced age
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> 80% diagnosed beyond age 65
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Highest incidence in African-Americans
– Younger age at diagnosis
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Family history / genetics (5-10% cases)
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High saturated fat diet
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Prostate Ca: Presentation
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Many are asymptomatic (PSA Screen)
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Difficulty with urination, hematuria,
nocturia, dysuria
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Bone pain from metastasis
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Prostate Ca: Evaluation
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Digital rectal exam (DRE)
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Trans-rectal ultrasound, biopsy
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PSA, alk phos
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Pelvic CT, bone scan
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Abdomen/pelvis CT, Bone scan
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Prostate Ca: Treatment
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Dependent upon stage, age, medical condition
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Options include surgery and radiation for
localized disease, Immunotherapy,
Radiopharmaceutical
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Hormonal therapy, chemotherapy for advanced
disease
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“Active Surveillance” or “Watchful Waiting”
appropriate for low grade tumors and for older
men
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Prostate Ca: Survival
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Dependent upon stage at diagnosis, grade
of tumor, medical condition
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Metastasis usually involves bones
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Survival can be very long
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5 year (99%), 15 years (93%)
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Prostate Ca: Screening
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Controversial / ? Survival benefit
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US Preventive Services Task Force
– Insufficient data to recommend for or against PSA screening
– Screening trials have yielded conflicting results
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ACS recommends
– annual DRE for age > 40
– annual PSA for age > 50
– if either suspicious, then U/S + biopsy
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