An overview to help patients or families who want to better understand cancer, outcome and treatment options

1. Cancer
Robert Miller MD
www.aboutcancer.com

2. What is Cancer?
“Cancer is a name given to a collection
of related diseases, where some of the
body’s cells begin to divide without
stopping and spread into surrounding
tissue.”
www.cancer.gov

3. What Causes Cancer?
Cancer is a genetic disease—that is, it is caused by changes to genes that
control the way our cells function, especially how they grow and divide.
Genetic changes that cause cancer can be inherited from our parents(germ
line). They can also arise during a person’s lifetime as a result of errors
that occur as cells divide or because of damage to DNA caused by certain
environmental exposures (somatic mutations).
Each person’s cancer has a unique combination of genetic changes. As
the cancer continues to grow, additional changes will occur.

4. ‘Driver’ Mutations
Each cancer is characterized by
numerous somatic mutations, of which
only a subset contributes to the
tumor’s progression.
Scientists want to be able to
distinguish these “driver”
mutations from the
preponderance of neutral
“passenger” mutations that
characterize each cancer,

5. Genetic Drivers of Cancer
The genetic changes that contribute to cancer tend to
affect three main types of genes:
Proto-oncogenes are involved in normal cell growth and division. When
these genes are altered they may become cancer-causing genes (or
oncogenes), allowing cells to grow and survive when they should not.
Tumor suppressor genes are also involved in controlling cell growth and
division. Cells with certain alterations in tumor suppressor genes may divide
in an uncontrolled manner.
DNA repair genes are involved in fixing damaged DNA. Cells with mutations
in these genes tend to develop additional mutations in other genes.
Together, these mutations may cause the cells to become cancerous.

6. Understanding Cancer
Type: there are more than 100 types of cancer. The cancer is usually
named after the site where it starts and are called carcinoma. There are
unusual types like sarcoma, leukemia, myeloma or lymphoma. The biopsy
or pathology report will describe the type of cancer and often include
multiple other important factors that can effect the prognosis (or outcome).
Stage: how far the cancer has spread. There are generally 4 stages of each
type of cancer and currently the AJCC (American Joint Committee on
Cancer) 7th edition staging system is used which came out in 2010. The
pathology report, the findings from surgery (if done) and imaging studies
(e.g. CT scans, MRI scans, PET scans) are all used to try to determine an
accurate stage.

7. Path Report
The diagnosis of cancer usually starts with a biopsy of the
tumor (histology) or cancer mass (if possible) or collection
of cells (cytology) from the patient. Important things to look
for on a pathology report:
1. Type of cancer (where did it start and is it a specific subtype)
2. Invasive or not
3. Size and depth of invasion
4. Other structures invaded (like lymph nodes or nearby structures)
5. Grade or measure of how mutated or fast growing the cancer is
6. Margins (has it been completely removed)
7. Other specific risk or prognostic factors (hormone receptors, vascular
or perineural invasion, proliferation score, ulceration and many other
important site specific factors)
8. Genetic profile (e.g. BRACA, ALK, HER2, luminal, Oncotype DX,
EGFR, etc. including NGS or next generation sequencing)

8. Genetic Profile
Oncotype will determine the risk
of a recurrence

9. Genetic Profile
MammaPrint will determine
whether adding chemotherapy
(CT) to endocrine therapy (ET)
will improved the cure rate

10. Genetic Profile
Prosigna will classify breast
cancer into a molecular category
that will have much different risks
of recurrence

11. Using Adjuvant Online to Calculate
the Benefit from taking
Chemotherapy based on genetic
recurrence risk score
Low risk
High risk

12. Understanding Cancer
Stage: how far the cancer has spread. There are
generally 4 stages of each type of cancer and
currently the AJCC (American Joint Committee
on Cancer) 7th edition staging system is used
which came out in 2010.
The pathology report, the findings from surgery
(if done) and imaging studies (e.g. CT scans,
MRI scans, PET scans) are all used to try to
determine an accurate stage.

13. Understanding The Stage
AJCC 7th Ed Staging System is based
on the TNM System
T: stand for tumor and cancer be based on size or depth of
invasion and commonly goes from T0 to T4
N: stands for lymph node spread based on the number of
nodes, size of nodes or location of nodes and is usually from N0
to N3
M: stands for evidence of distant metastases and is usually M0
or M1
Stage: generally combines all 3 of these (and sometime other
factors as well) to group patients into stage categories generally
from 0 to 4 but can include sub stages like IVa , IVb or IVc

14. For breast cancer, the size and number of nodes combine to determine
the stage

15. For colon cancer, the depth of invasion is critical to determine the stage

16. Understanding The Stage
Why is the stage
important?
Because it guides
treatment strategies and
predicts outcome and

17. Survival by Stage for Breast
Cancer
Years
0
I
II
III
IV

18. Understanding
Treatment Options

19. Treatments
1.No treatment (either unnecessary, won’t
work anyway, it’s not worth it to
the patient)
2.Surgery
3.Radiation
4.Chemotherapy
1.Conventional chemotherapy
2.Hormone Therapy
3.Immunotherapy
4.Targeted Therapy/ Precision
Medicine

20. Surgery : local treatment, may be disfiguring but if
the tumor can be removed it is quite successful
Radiation: regional treatment, may have less side
effects then surgery, successful if the cancer is radio-
sensitive
Chemotherapy: widespread, treats the whole body,
may have significant side effects, success depends
completely on whether the cancer is sensitive to the
available drugs
Basic Treatments

21. Combined Modality Therapy in the
Treatment of Pediatric
Rhabdomyosarcoma
Treatment 5 Year Survival
Surgery 10 – 20%
Surgery plus PostOp Radiation 40 – 50%
Surgery, Rad. then Chemotherapy 80 – 90%

22. Precision Therapy
Precision or targeted therapies work by exploiting the molecular
underpinnings of cancer. The precision of cancer treatments
has become more sophisticated with each passing year.
Therapies that attack multiple genetic drivers of cancer in
combination or harness the body’s own immune system to
attack tumor cells have improved outcomes for patients with
difficult-to-treat cancers.
Of all the newly FDA-approved cancer therapies approved in
2015, 12 (62.5%) are classified as precision therapies.

23. New Cancer Drugs and Biological FDA
Approved in 2015

24. Best Treatment
How do patients know if they are receiving the
best, current available therapy?

25. Treatment decisions should be made by the patient and
family in consultation with a multi disciplinary panel of
cancer specialists c/w current NCCN guidelines. These
can be accessed free online at NCCN.org or the patient
site at www.nccn.org/patients

26. Treatment decisions should be
made by the patient and family in
consultation with a multi
disciplinary panel of cancer
specialists c/w current NCCN
Should be a
Team
Approach

28. www.nccn.org/patient
s

29. Prognosis
Note that there are many factors that effect
the odds and length of survival
1.The type and location of the cancer
2.The stage and site of spread
3.The cancer grade or speed of growth
4.Other specific traits of the cancer cell
5.The patient’s own health,
age and performance score
6.The response to treatment

30. 0 – Asymptomatic (Fully active, able to carry on all pre-disease activities
without restriction)
1 – Symptomatic but completely ambulatory (Restricted in physically
strenuous activity but ambulatory and able to carry out work of a light or
sedentary nature. For example, light housework, office work)
2 – Symptomatic, <50% in bed during the day (Ambulatory and capable
of all self care but unable to carry out any work activities. Up and about
more than 50% of waking hours)
3 – Symptomatic, >50% in bed, but not bedbound (Capable of only
limited self-care, confined to bed or chair 50% or more of waking hours)
4 – Bedbound (Completely disabled. Cannot carry on any self-care.
Totally confined to bed or chair)
5 – Death
ECOG Performance Score

31. JOP September 2014 vol. 10no. 5 e335-
e341
Survival in Patients with Advanced
Cancer Based on Performance Score

32. If the patient has a good response to
treatment then survival will be prolonged

33. Survival with Advanced Colon Cancer
Based on the Response to
Chemotherapy

34. Impact of Response to Chemotherapy on
Breast Cancer Patients by Cancer Type
Luminal- A Type Cancers Triple Negative
Definition and Impact of Pathologic Complete Response on Prognosis After Neoadjuvant
Chemotherapy in Various Intrinsic Breast Cancer Subtypes
JCO May 20, 2012 vol. 30 no. 15 1796-1804

35. Recommended Web Sites from
Doctor Miller
 The best site would be the NCCN / esp. the patient
site: www.nccn.org or www.nccn.org/patients
 The next best would be from the NCI (National
Cancer Institute) or CancerNet at www.cancer.gov
the NCI booklets are very good at
www.cancer.gov/publications/patient-education
 CancerNet from ASCO (American Society of Clinical
Oncology) is very good at www.cancer.net
 American Cancer Society at www.cancer.org is
good
 Finally Doctor Miller’s site at
www.aboutcancer.com has a large amount of
information and a medical video channel