1. Cancer Studies
Year 4
Attachment 2

2. Principles of Oncology
• Cancer affects 1/3, kills ¼ (our generation ½, 1/3)
• Incidence is rising but mortality falling
• NI: skin cancer most common
• NI: CHD biggest killer, soon cancer will overtake it
• Cancer in men is overall decreasing as fewer now smoke
• Cancer in women is rising overall as more now smoke
• Clinical detection:
– clinical presentation e.g. breast lump, PR bleeding
– Screening e.g. smear
– Incidental finding: routine CXR
• Principles:
– Reduce incidence: prevention
– Improve outcome: early detection, effective treatment, screening
– Improved outcome = higher cure rate/better QOL/longer survival rate
• Diagnosis of cancer: Hx, examination, tissue diagnosis, staging

3. Aetiology of Cancer
• Genetic predisposition
• Environmental:
– lifestyle factors: smoking (all cancers), alcohol, obesity (oesophageal/gastric/HCC)
– Industrial carcinogens: Asbestos, nanotechnologies
– Drugs, radiation: CT scan, radiotherapy, radon, phone masts
• Immunodeficiency: HIV, post-transplant
• Other pre-disposing medical conditions: UC/CD, barretts, hepB
• SMOKING!!!! Implicated in ALL cancers
• Prevention
– Diet: changing from high fat and low fibre
– Infection: HPV, HBV, H pylori, EBV: vaccines
– Reduced sun/UV exposure
– Stop smoking: early education, get smokers stopped
– Screening!!!
• Breast: mammography every 3 years without clinical exam 50-69
• Cervix: smear test using liquid based cytology, every 3yrs 25-49, 5yrs 50-64
• Colon: faecal occult blood, every 2years 60-71. polyps etc not always bleeding

4. Principles of Oncology
• Staging: TNM
– T based on size generally, N nodes involved, M for METS (x=unknown)
• Treatment Modalities
– Surgery: aim for organ and functional conservation, minimally invasive
– Radiotherapy
– Systemic therapy: chemo, hormones (prostate, breast, endometrial), targeted therapies
– Palliative and supportive care
• Principles of Treatment
– Depends on site, cell type, extent, co-morbidities, pt wishes
– Intent must be clarified:
• curative (radical)
• Palliative: no cure possible, symptom relief and better QOL
• Adjuvant: improve outcome e.g. prevent recurrence
• Neo-adjuvant: additional therapy before definitive therapy e.g. to shrink tumour before Sx
• Performance Status
– 0: asymptomatic (their normal even with co-morbidities)
– 1: symptomatic but fit to get around
– 2: symptomatic, resting <50% of day
– 3: symptomatic, resting >50% of day
– 4: bedbound, no self care
– 5: Dead

5. Principles of Oncology
• Future of cancer care
– Challenges of ageing population
– Importance of cancer prevention: lifestyle modifications
– Improved screening
– Delivery of comprehensive and co-ordinated services: MDT, specialists
– Development of better Rx: clinical trials
– Refine local therapies: improved targeting of radiotherapy, less invasive Sx
– Better systemic therapies: more effective, less toxic, oral, long term use
– Personalised/stratified medicine: gene therapies e.g. EGFR gene
– Net effect better therapeutic ratio: more cost effective and better outcomes

6. Cancer Management
• Principles:
– Diagnosis
– Staging: TNM
– Predicting outcomes
– Adapting theory to risk
• General Principles
– WHAT IS IT: biopsy
– WHERE IS IT: scans
– WHAT ARE YOU GONNA DO NEXT?????
• Management plan
– Investigation: do we know enough?
– Treatment: tailored to each individual, intent?
– Modality: surgery, chemo, radio, hormones, combination?
– MDT: meetings, plan, review and follow up
• Predicting outcome:
– Tumour type, size, status, stage
– Patient: performance status, co-morbidities, support
• Tumour markers: AFP testicular and HCC, bHCG testes, CEA colorectal, CA19-9
pancreas, CA125 ovary and PSA prostate (LDH testes)

7. Breast Cancer
• Most common female cancer, affects 1/9 women (NI 1000/year)
• RFs:
– Post menopausal obesity
– Few pregnancies, no breastfeeding
– Higher social class
– SMOKING
• Can occur in a familial pattern: 5%
– Younger age of onset
– Bilateral disease
– Autosomal dominant: men carry, women express. Must ask full FHx
– Key mutations: BRCA1- 1/3ovarian, 2/3 breast. BRCA2- 10% ovarian 70% breast
• Presentation and Diagnosis
– Painless breast lump
– Asymptomatic screening
– Skin erythema/oedema
– Nipple inversion/scaling/bleeding
– Symptoms of METS: nodal masses, bone pain, SOB, anorexia
• Triple assessment: examination, imaging (US/Mamm), biopsy (FNA/core)

8. TNM Breast
• T1: <2cm
• T2: 2-5cm
• T3: >5cm
• T4a: chest wall involved
• T4b: skin involvement
• T4c: both chest wall and skin involvement
• T4d: inflammatory (cellulitis like ulcerated picture)
• N0: no nodes involved
• N1: 1-3 nodes involved
• N2: 4-9 nodes involved
• N3: 10+ nodes involved
• Nx: nodal status unknown
• M0: no METS
• M1: METS
• Mx: MET status unknown

9. Breast Cancer
• Predicting outcome:
– Look at prognostic factors: NODAL STATUS, age, co-morbidities, smoking status,
tumour type & stage, receptor status: ER + better than - , Her2 + worse than -
– Classify risk of relapse
– Inform pt of risk and follow up
– Determine best treatment strategy
• Primary Management:
• Surgery:
– Local control, possible cure, gives prognostic info, treats breast +/- axilla (nodes)
– Options include: simple mastectomy +/- radiotherapy, partial mastectomy (2/3) and
radiotherapy. Reconstruction surgery also available
– Let patient choose where possible
– Contra-indications to partial: large tumour in small breast, tumour behind nipple,
multi-focal tumour, patient choice
– Management of the axilla: no longer surgical clearance. Sentinel node biopsy!! Only
1/3 node positive – no point causing lymph oedema for no reason.

10. Breast Cancer
• Radiotherapy:
– Post-operative radiotherapy (XRT): local relapse 25-30% with surgery only,
radiotherapy reduces relapse to 5%, equivalent to mastectomy. Not needed in total
mastectomy unless T3-4 or +ve nodes
– Adjuvant: day pt procedure, 15-30 fractions, 3-6weeks of daily visits, minimal toxicity
– skin erythema, pneumonitis.
• For all patients with partial mastectomy: radiotherapy to breast only
• Mastectomy patients: radiotherapy to chest wall only if high risk local relapse
• Adjuvant systemic therapy
– High risk pts may have early spread, you can reduce the risk of death by eliminating
stray cells (micro-METs)
– To prevent relapse after surgery due to micro METs, systemic therapy can eliminate all
cells if given when cells are scarce
– Hormonal: 2/3 breast cancer ER/PR +, cells are sensitive to anti-oestrogens. Reduce
risk of dying by 30% in ER + tumours.
• Tamoxifen 20mg daily for 5years
• Aromatase inhibitors can be used in post-menopausal women. It converts fat to oestrogen so stop that
and risk of relapse decreases.
• Both together gives best outcome
• Ais not useful in younger patients.

11. Breast Cancer• Chemotherapy
– FEC - 5FU, epirubicin cyclophosphamide
– FEC-Docetaxel: more toxic but more active, FEC x3 weeks then Docetaxel x3 weeks
– Improves outcome
– Less effective in >65
– Taxanes improve outcome by 3-6% in node positive pts. More toxic, saved for node +
• Adjuvant chemo:
– given to all node + pts of moderate/high risk. RISK BENEFIT ratio
– Give FEC100 +/- docetaxel
• Trastuzumab/Herceptin
– Trans-membrane receptor, over-expressed in 20% breast Ca. HER + worse than –ve.
– Activation gives growth stimulus to cell, associated with aggressive tumour, poor Px
– Relapse reduced by 50% at 2years. Better RR to chemo.
– A/Es: 1/7 reduced ejection fraction, 1/200 cardiac failure. Reversible
• Metastatic Breast Cancer
– Presents with symptoms of bone, lungs, liver, brain. RESTAGE on Dx
– Pt needs restaging to determine extent, aim then is symptom control: 5-10% alive at 5yrs
– Preference for hormone therapy if ER + and chemotherapy if ER -
**NOT CURABLE. Good initial response but 90% relapse in 2years

12. Breast Cancer
• Chemotherapy agents:
– Anthracyclines: doxorubicin, epirubicin – FEC, FAC
– Taxanes: docetaxel, paclitaxel
– FEC: 5Fluoro-uracil, Epirubicin, cyclophosphamide
– FEC: 6 doses for stage 1
– FEC 3doses, docetaxel 3 if worse
• Single agent response rate 20-40%
• Combination therapies RR 50-80%
• Assessment of outcome
– Assess toxicity every cycle: PS, weight change, A/Es, QOL, intensity and duration
– Assess tumour response every 3cycles: clinical, imaging, tumour markers
– Stop if disease progression
• Chemo for Breast Cancer:
– FEC
– Taxane +/- trastuzumab (herceptin)
– Capecitabine or vinorelbine

13. Breast Cancer
• Outcomes should improve because of:
– Earlier presentation 2o to education and awareness
– NHS screening scheme
– Specialised clinics
– Adjuvant therapy: chemotherapy, tamoxifen, trastuzumab
– Better outcome for advanced disease
– 30% reduction in death rates from 1985-2000
• Administering Chemotherapy
– Must wear gloves, eye protection, sleeves and mask
– Must use cannula. Never a butterfly

14. Cancer Registry
• 3 most common cancers in women: (skin) breast, lung, colorectal
• 3 most common cancers in men: (skin) Prostate, lung, colorectal
• Input: GP registry, death certificates, pathology labs, hospital admissions
• NI 10,500 cancers a year
• 8,000 excluding non-melanoma skin cancers (NMS)
• 3,500 cancer deaths
• At least 40,000 living with cancer (24,000 exc NMS)
• 1/3 chance getting cancer by age 75 (1/4 if exclude NMS)
• 1/5 deaths are cancer related
• Rates higher in men than women:
– More genetic x-linked causes
– Physiological differences
– Behavioural factors: smoking, alcohol, going to Dr
– Work place
• Risks differ within different subgroups: med students V roden street

15. Cancer Registry
• Young cancers: testis, cervix, malignant melanoma, breast, ovary,
leukaemia/lymphoma
• Old cancers: kidney, stomach, colon, oesophagus, lung, prostate
• Higher affluent pop more likely to get
– breast cancer: less children, no breast feeding, more likely to have HRT
– Skin cancer: more likely to have sunny holidays
• Causes of cancer
– Genetics: BRCA1
– Race
– Geographical variation
– Lifestyle and environment: diet, tobacco, obesity, alcohol, radiation exposure, sun
exposure, carcinogens (asbestos, viral infections)
• Tobacco related cancers: oral, lung, larynx, stomach, oesophageal,
pancreas, cervix, kidney, bladder
• Prevention
– Early detection: awareness, screening, education, 2o prevention
– Lifestyle modifications: diet, smoking, weight, exercise, fibre, vaccines/Abx

16. Prevention
• Stomach (242/yr)
- ↓ intake of salted, smoked or pickled food.
- ↑ fresh or frozen foods (use of freezers/fridges).
- control Helicobacter Pylori infection.
• Breast (1,000/yr)
- ↓ dietary fat.
- NHS screening programme (age 50-70).
- genetic testing for BRCA1/BCRA2 mutations in high risk women & surveillance.
- exercise 4-5 hrs/wk.
- address obesity in post menopausal.
• Colorectal (930/yr)
- ↓dietary fat & red meat consumption.
- ↑ fibre in diet.
- screening of high risk individuals.
- regular exercise ↓ risk by 40-50%.
• Oesophagus (154/yr)
- ↓ tobacco & alcohol.
- ↑ fresh fruit & vegetables & ↓ exposure to nitrosamines.

17. Prevention
• Lung (900/yr)
- Address tobacco use.
- Primary prevention - education.
- Environmental tobacco control.
- Secondary prevention - stop smoking strategies.
• Melanoma (233/yr)
- Primary prevention Care in the sun - seek shade 11am-3pm.
- Cover up(hat, shirt & sun glasses, sunscreen).
- Secondary prevention - awareness of symptoms.
• Prostate (915 in 2007) (486 in 1994)
- PSA testing in asymptomatic men is not currently recommended as there is
no scientific consensus that screening is beneficial.
- PSA test is not specific enough as it can be elevated in non-malignant
prostate conditions.

18. Cancer Registry
• Cancer survival
– Site of cancer
• Breast 82% 5year survival
• Lung 5-10% 5year survival
• Oesophagus 13% 5year survival
• Prostate 60% 5year survival
• CRC 55% 5year survival
– Stage of cancer at diagnosis and cell type
– Highest for: testicular, malignant melanoma, breast, hodgkin’s
– Lowest for: mesothelioma, lung, liver, pancreatic
• Cancer increasing? Population increasing, ageing pop, better diagnostic
tools, control of other diseases, screening. 30% increase in next 20yr
• Period effect: high profile case, people go to get checked so more
diagnoses made e.g. Jade Goody, Kylie Minogue
• Cohort effects: vaccine introduced or new treatment developed. One
group who travel through time together, affected by same thing
• Better outcome: specialists, single operators, MDTs, prevention, early
detection, putting research outcomes into practice

19. Prof Spence: Surgery
• Middle aged and PR bleeding: suspect CRC
• Pagets disease of the nipple, commonly on exams. Underlying cancer
creeps through ducts and onto the skin. Treatable.
• Seminoma: testis tumour. Grossly pink/grey colous. Even if caught late
should survive. Rx: orchidectomy, chemo, radio (nodes)
• 1/3 UK develops cancer
• ¼ UK dies from cancer
• NI 4000 cancer deaths/year
• 23% all deaths due to cancer
• Second most common cause but will be first soon
• Bowens disease of the penis: pre-malignant before SCC. Rx: amputation
• Mesothelioma: death by crushing lungs so 0 lung function
• Male: lung, colon, stomach, prostate, pancreas
• Female: breast, lung, colon, ovary, pancreas
• KNOW COMMON CANCERS – FINALS!!! Also prostate is topical so know,
pancreas often asked on exams.

20. Prof Spence
• Screening!!!!!!!
– Breast: 50-70 screened by mammography every 3years. Letter to say
normal/abnormal and recalled. At recall physcial exam, imaging and biopsy (triple
assessment). Mamm painful. 10% abnormal and recalled. Can be benign e.g. cyst.
– Cervix: must have intercourse to get cervical cancer. HPV passed from the male.no
trial to say It is good. Cervical smear every 3-5years from age 25. Done by GP
– Colon: >60 males and females sent out a faecal occult blood sample kits. Polyps or
early tumours ooze blood almost constantly in trace amounts. Can be picked up. If
abnormality detected, sent for colonoscopy: 1/1000 perf and you can die. Test CAN
KILL YOU. Compliance an issue – who wants to poo in a dish?
– Lung: high risk patients e.g. asbestos exposure or heavy smokers get CT scans to
pick up early lung cancer. 1/2500 screening causes 1 lung cancer from radiation.
USA
– Prostate: 60% have prostate cancer at 60, 70 at 70 etc. PSA blood sample taken,
raised PSA may indicate prostate cancer. No perfect Rx. Radical prostatectomy
causes impotence, incontinence etc. radiotherapy causes proctitis and pelvic pain,
hormone therapy has many A/Es as does chemo. Trials ongoing: results just in time
for finals!!!
– Not cancer: AAA: survival 50%, find before rupture and treat when >5.5cm. US scan.

21. Prof Spence
• Screening: benefit, cost, accuracy, counselling, compliance (fear/embarassment),
A/Es
• Screening for breast:
– 50-64years 3yearly mamm.
– Bad family history
– Test: examination, US, mamm, genetics
• Want to avoid unnecessary surgery eg if widespread METs. Can do this by
appropriate investigations – CT, MRI, laparoscopy, intra-operative US
• Liver 2o from colon: don’t give up: treatable. From anywhere else no point
• Treatment decision: involve family, patient, MDT, best available data
• Ethics: consent, confidentiality, pt autonomy, special cases – children and
elderly, incompetent patients
• Take precautions to avoid damaging healthy tissue e.g. eye shield in face SCC
• Palliative measures taken to IMPROVE QOL.
• Rx: surgery, chemo, radio, hormones, embolisation (breaks tumour up),
immunotherapy: generally only melanoma

22. Prof Spence
• Stroke in old person: probably stroke. Stroke in young person: probably
tumour!! Or venous malformation
• Beware of funny looking things. TB, syphilis and cancer mimic eachother
• Beware of fractures in young people without a proper reasons: bone 1o.
Older patients more bone 2o or other bone disease
• Primary surgery: excise tumour and surrounding normal tissue to 1cm
• Can give pre-op radio/chemo
• Post op: radio, chemo
• Breast reconstruction: TRAM flap, lat dorsi flap, implants
• Laparoscopic bowel surgery now possible and safe for cancer resection
• Prophylactic surgery: colectomy in FAP (APC gene), mastectomy +/-
hysterectomy in BRCA1/2
• Start screening from 10years before youngest family member developed
their cancer
• Lymphoedema in patients with node clearance in breast cancer

23. Lung Cancer
• Incidence:
– 41,500 cases in 2009 UK (1000 NI)
– 35,000 lung cancer deaths in 2010
– 75-80% dead within 12months of diagnosis
– Accounts for 6% of all UK deaths and 20% of all cancer deaths
– 5year survival rate = 7-10% POOR PROGNOSIS
– 1 year survival rate = 30%
– Most common cancer worldwide (1.61m)
– (skin) breast, LUNG in descending order
– Big 3: Breast, Lung, GI
– Incidence is decreasing in males: fewer smoking
– Incidence is increasing in women: more smoking
• Prevention and Early Detection
– Education: drs telling pts, public health campaigns, non smoking day, smoking ban,
asbestos regulations
– Low threshold for investigation
– Screening: (negatives: exposed to radiation, find something-needle introduced
which could cause pneumothorax, people may continue to smoke, thinking cancer
will be picked up early so they are ok)

24. Lung Cancer
• Presentation
– Haemoptysis
– Cough
– Chest/shoulder pain
– SOB
– Weight loss
– Chest signs: creps, wheeze, dull
– Hoarseness (means T4 is involved and generally non-resectable)
– Finger clubbing
– Cervical/SCF nodes
– Features indicating METS: brain, liver, bone
• Alarm symptoms:
– Change in cough (smoker)
– Recurrent chest infections
– Change in smoking habits: suddenly stopping
– Middle aged male spontaneously visits GP worried
• Typical Person:
– Smoker, emphysema, bronchitis, heart disease, male >50
Often incidental finding
on CXR for another
reason!!!

25. Lung Cancer
• Investigations:
– Bloods…
– CXR: can present as obvious tumour mass, lobe collapse, lung collapse (bronchial),
nodal involvement
– CT chest, abd, pelvis: for staging and better information on size and location
– PET CT: METs, nodes involved and size of tumour
– Bronchoscopy: get a view of tumour +/- biopsy if possible
– Mediastinoscopy: view and biopsy if possible.
– Biopsy: want to know cell type eg squamous. Different treatment and prognostic
factors. Small cell or non-small cell then specific type of non-small cell.
• Histology
– Small cell: 10%
– Non-small cell: 90%, squamous cell carcinoma, adenocarcinoma, large cell
carcinoma, bronchioalveolar carcinoma, mixed, Not otherwise specified
• Performance Status
– 0: asymptomatic
– 1: symptomatic but able to carry out light work
– 2: in bed <50% of the time
– 3: in bed >50% of the time
– 4: bedridden

26. Lung Cancer
• TNM
– T1a: <2cm
– T1b: 2-3cm
– T2a: 3-5cm: must be 2cm from the carina
– T2b: 5-7cm
– T3: >7cm or directly invading chest wall…potentially resectable
– T4: invasive tumour that cant be removed
– N1: ipsilateral bronchopulmonary or hilar nodes
– N2: ipsilateral mediastinal/subcarinal nodes
– N3: contralateral mediastinal nodes
– M1a: separate tumours nodules in the other lung/pleural nodules/malignant pleural
or pericardial effusion
– M1b: distant METs

28. Lung Cancer
• Factors influencing treatment:
– Performance status
– Respiratory function: FEV1 (% predicted), transfer factor, VO2 max
– Exercise tolerance
– Co-morbidities
– Motivation
– Cardiac function ECG/ECHO/CPEST(cardiopulm exercise stress test)
• Treatment

29. Lung Cancer
• Small cell:
– 70-80% responsive to chemo
– Staging: limited stage scc (20%), extensive stage scc (80%)
– Treatment: chemotherapy and radiotherapy. NOT surgery.
– Spreads rapidly: can deteriorate and die within weeks
– Limited stage: limited to radiotherapy field
– Chemo or palliative radiotherapy
– Prognostic factors: stage, performance status, Na, LDH, Alk Phos
• Surgical options: lobectomy or pneumonectomy(whole lung)
• 20% pts suitable for surgery
• concurrent chemotherapy: 20-30% full cure
• Investigations: IBS (bone scan), USS neck, thyroid bloods, CXR, CT,
bronchoscopy, mediastinoscopy
• Adenocarcinoma
– RR chemo: 1/3 shrinkage, 1/3 same, 1/3 progress regardless
– EGFR mutation important: epidermal growth factor receptor. A new target for
therapies e.g tyrosine kinase inhibitor
– Chemo: docetaxel 2nd line

30. Lung Cancer
• Mesothelioma
– Survival <1year
– Often causes malignant pleural effusion: drain
– Pleural biopsy for diagnosis
– Can leave a catheter in situ to drain effusion long term
– Ask about asbestos exposure, weight and appetite
– Management:
• palliative chemotherapy ONLY if PS0/1
• Pemetrexed and cisplatin: increase survival by 3months
• Radical management
– Surgery
– Radical radiotherapy/SABR/4DCT
– Chemo-radiotherapy
• Palliative management
– HDP radiotherapy
– Single fraction radiotherapy
– Palliative chemo and TKIs (EGFR: can be a response if EGFR –ve, might not be even if EGFR
+ve)
– Palliative surgical interventions
– Symptom control team

31. Urological Cancers
• Prostate
• Bladder
• Kidney
• Ureter
• Urethra
• Penis
• Testis
• Do I know what it is? Biopsy, TNM
• Do I know where it is? CT, MRI, PET
• Do I know how to treat it? Surgery, Chemo, Radiotherapy, Hormones
• Symptoms: urinary frequency, nocturia, hesitancy, back pain,
haematuria, dysuria, poor stream
• Prostate exam: is the prostate firm/irregular/nodular
• Any areas of tenderness: on the back

32. Urological Cancers
• Investigations
– PSA test: normal value 0.5-4ng/ml. anything higher ?should be investigated as
possible prostate cancer
– U&E, FBP
– TURP, IBS
– Biopsy: excision or core

33. • T1: cant see/feel
• T2: see and feel,
Confined to prostate
• T3: breaking out of
Prostate capsule
• T4: other organs
invaded
Investigations
PSA
Isotope Bone Scan
U&E, FBP
TURP
Biopsy

34. Urological Cancers
• Gleason grade
– Scores 1-5: 1 is normal tissue, 5 is highly abnormal.
– 2 numbers given: first one is the most common cell type, then the majority of the
rest of the cells
– Number given out of 10.
– E.G. gleason 7with 4
• Supportive Therapies
– Dietetics
– Financial support
– Psychological support
• Surgery: Radical Prostatectomy (open, laparoscopic, robotic)
– Early complications: incontinence, impotence
– Late complications: incontinence, impotence
• Prognostic Factors
– Low risk: PSA <10ng/ml. gleason score <6. clinically T1-T2a
– Medium risk: PSA 10-20. Gleason 7. clinically T2b or T2c
– High risk: PSA >20. Gleason 8-10. clinically T3+

35. Urological Cancers
• Prostate Cancer Radiotherapy
– Target identification: tumour, prostate. Seminal vesicles
– Organs at risk: rectum, bladder, penile bulb
– Hits prostate and rectus
– A/Es: mucositis of rectum, bladder, colon, ureters…any complication of these
– IMRT: intensity modulated radiotherapy: NEW, better, good control of doses, multiple
energies, rectum etc shielded. Higher dose to prostate, less to organs
– Old: conformal radiotherapy. Less direct
• Reduce testosterone, leaves
Cancer stable for a while.
By hormone therapy (effectively
Switches off pituitary production of
Testosterone. “chemical castration”.
Or orchidectomy to remove testicles and
Prevent testosterone production that way.

36. Urological Cancers - Prostate
• Brachytherapy:
– Insertion of small radioactive pellets into the prostate which leaks out locally and
gives very high dose radiotherapy to prostate only
• Outcome:
– Good if organ confined
• Follow Up
– PSA monitoring: stays low is good. If increasing the rate is important
– Metastatic disease possible after 3-4years if huge rise in PSA
• Ask if a smoker!!!!!
• History: chemicals, radiation exposure, smoking
• If smoker with haematuria: BLADDER CANCER until proven otherwise
• Investigations:
– Biopsy, TURB
– IVP
– CT urography, CT Chest/Abd/Pelvis
– IV urogram
– Cystoscopy
– If one part of the mucosa is affected its likely others will be too. More tests needed!

37. IVP
• An intravenous pyelogram (IVP) is an X-ray test that provides pictures of
the kidneys, the bladder, the ureters, and the urethra (urinary tract ). An
IVP can show the size, shape, and position of the urinary tract, and it can
evaluate the collecting system inside the kidneys.
• During IVP, a dye called contrast material is injected into a vein in your
arm. A series of X-ray pictures is then taken at timed intervals.
• IVP is commonly done to identify diseases of the urinary tract, such as
kidney stones, tumours, or infection. See a picture of an IVP showing a
kidney stone . It is also used to look for problems with the structure of the
urinary tract that were present from birth (congenital).
• An ultrasound or a computed tomography (CT) scan may be combined
with an IVP if more details about the urinary tract are needed. A
computed tomography intravenous pyelogram (CT/IVP) is usually done to
look for the cause of blood in the urine.

38. Urological Cancers - Bladder
• On CT: looking for filling defect and fluid
level
• MRI not used much for pelvis
• Management:
– Radical or palliative
– Local or systemic: hormones don’t work
– Chemo: BCG for localised, with reduced
recurrence. Not deep enough for >T2
– pT2 65% RR surgery
– Radiotherapy not as good: 50% RR. Potential
curative option if surgery not an option
– Chemo after surgery – might have a role
– 35% recur with METS. May already have METs.
Chemo will destroy remaining cells. 3 cycles of
chemo.
– Neo-adjuvant chemo improves outcome by 5%
over 5years
– Most are pTa or pT1
– Radical therapy needed after pT2

40. Urological Cancers
• Renal tumours:
– Management: surgery no matter what the stage. Debulking of tumour best
– Radical or palliative
– If expansile lytic mass found as MET in bone: almost ALWAYS kidney (could be
thyroid, pancreatic or lung)
– Presentation: loin pain, mass, haematuria
– Examination: no signs often, possibly mass
– Investigations: renal function, IVP, CT urography,
MRI IBS
– Management: surgery, adjuvant therapy?
– Outcome:?

41. GI Cancer
• CRC: 900-950 cases per year NI
• 400-430 deaths per year NI
• One of the most common solid cancers
• More common in developed countries:
– Diet: high salt, red meat, processed foods, low fibre, high fat
– Obesity
– Increased life expectancy
• Death rates dropping off for males and females
• History: PR bleeding, change of bowel habit
• Risk Factors
– General: age >40, family history (1st degree)
– Pre-existing: IBD, previous CRC, previous radiotherapy, neoplastic CR polyps
– Genetic: FAP, gardner/oldfield/turcot syndrome, Peutz-Jeghers sundrome, HNPCC –
lynch ½
– See below!!!

42. CRC
• Early stages
– asymptomatic
– Abd pain, flatulence, minor changes to bowel habit, rectal bleeding, anaemia
• Late Stages
– Sigmoid colon: constipation/diarrhoea, abd colicky pain, obstruction – N&V
– Caecum: vague abd aching, anaemia, weakness, weight loss
– Rectum: change in bowel habits, rectal/pelvic fullness, urgency, bleeding, tenesmus,
pelvic pain late
• Family History: colorectal cancer and endometrial part of Lynch
syndrome
• Screening:
– Faecal occult blood tests sent out to M&W 60-69 every 2 years
– If positive test: colonoscopy offered +/- biopsy
– Starts earlier for family history positive patients
– FAP: colectomy offered in early 20s when cancers have started developing, same for
HNPCC
– If personal history of adenomatous polyps or IBD

43. CRC
• Investigations:
– Abdominal x-ray
– Barium enema with contrast. Apple core stricture
– CT colonography – with contrast
– Colonoscopy with biopsy
• Staging
– CT chest/abdominal/pelvis for nodes and METs
– Biopsy for cell type etc
– Time of diagnosis: stage 1 15%, stage 2 20-30%, stage 3 30-40%, stage 4 20-25%
• Management
– Surgery
– Radiotherapy
– Chemotherapy
• Classification
– T in situ: tumour not invading mucosa
– T1: invading submucosa
– T2: invading muscularis propria
– T3: invading subserosa
– T4: invading through serosa and into adjacent organs

44. CRC
• Nx: unknown nodes
• N0: no nodes
• N1: mets in 1-3 nodes
• N2: mets in 4+
• Mx: unknown METs
• M0: no METs
• M1: distant METs
• Prognostic factors
– Stage
– Invasion of BVS or lymphatic vessels
– Numbers of involved local lymph nodes
– Tumour penetrated/perforated bowel wall
• Adjuvant therapy
– Overall survival always increased with chemo
– Doesn’t prevent relapse
– Surgery and chemo better than just surgery
– Chemo: 5FU
AJCC/ UICC Dukes*
Stage 0 Tis N0 M0 —
Stage I T1 N0 M0 A
T2 N0 M0 —
Stage II T3 N0 M0 B
T4 N0 M0 —
Stage III Any T N1 M0 C
Any T N2 M0 —
Stage IV Any T Any N M1 —

45. CRC
• Treatment
– Stage 1: T1/T2 – surgery alone
– Stage 2: T3/T4 – surgery. Adjuvant chemotherapy shows 2-4%% overall improvement in
cure rates
– Stage 3: surgery & chemotherapy with 5FU/folinic acid. 10-15% improvement in overall
survival.
– Stage 4: MET disease - palliative surgery may be appropriate, palliative chemo
• Rectal Cancer
– Pre-treatment investigations: same as colon cancer. MRI pelvis useful as its fixed in the
pelvis
– Surgery: total mesorectal excision is surgical procedure of choice. Radiotherapy prior to
surgery may be useful. Post op chemo for best outcome
• CEA tumour marker
• Follow up: pick up relapse. CT annually for 3years and regular CEA
• Sites of METs – liver 60%, abd lymph nodes 40%, lung 40%, peritoneum, ovary,
adrenal glands, pleura, bone, brain
• New drugs in CRC
– Oral fluoropyrimidines: capecitabine, UFT
– Irinotecan: better anti-tumour effect, same QOL
– Oxaliplatin: better anti-tumour effect and QOL

46. CRC
• Survival
– No treatment: 6-8months
– 5FU chemo: 11-14 months
– Combination therapy: 16-17 months
– Sequential use of combination therapy IF FIT: >20 months
• Future therapies
– Molecular markers: prognostic factors, predictive factors
– Novel therapies: receptor tyrosine kinase inhibitors, anti-angiogenic therapies, cell
cycle inhibitors, immunotherapy

47. Gynae Cancers
• Ovarian
– Presentation: abdominal swelling, tight skirts, constipation, urinary frequency, nocturia
– Investigations:
• abdominal and PV exam: palpate mass/nodes/METs
• USS abdomen: ascites, mass
• CT chest abdo pelvis: ascites, pelvic mass, omental cake infiltrate common
• Tumour markers: CA125 should be markedly elevated
– DDx: pelvic inflammatory disease, endometriosis, IBD. TB!!! Ovarian cancer,
KRUKENBERG METs (stomach primary that spreads to ovaries transperitoneally)
– Could be lobular breast cancer (lobular 10%) , stomach, CRC, pancreatic
– Ovarian cancer spreads transperitoneally. Even late its rare for it to spread anywhere
other than retrooperitoneal organs. Never really spreads haematogenously
– Spreads to colon, omentum, para aortic lymph nodes, liver, underside diaphragm
– 85% have METs at presentation
– Treatment:
• Surgery: gets rid of 1o tumour, unlike other cancers only spreads within the abdomen. Not
curative. leaves disease behind. SHOULD DEBULK AS MUCH OF TUMOUR AS POSSIBLE.
• Chemotherapy: carboplatin & taxol. Combination has best response rate: 70-80%. Very chemo
sensitive.
– Disease recurs after approx 18months after treatment and they live 2-3years
– Post menopausal woman: ovaries small so lots of room to grow – present late

48. Gynae Cancers
• Ovarian
– Chemo plus debulking surgery best prognosis
– Side effects of chemo: peripheral neuropathy
– Screening: ongoing trials looking at 0 screening/CA125 annually/CA125 & vaginal US
annually.
– Spreads into
• parametrium: nothing there so easy
• Rarely spreads to bladder or rectum – thick muscular wall too hard to get through
• Very very very late spread haematogenously
– 1/3 gynae cancers in NI
– Optimal debulking prolongs survival by 20months
– Best therapy: carboplatin and taxol
– Most patients relapse but some survive long term

49. Gynae Cancers
• Cervical Cancer
– Presentation: post coital bleeding, smoker
– Still occurs because people miss their smear appointment
– Investigations
• Vaginal examination: feel cervix – rough? Blood?
• Speculum: visible mass?
• FBP, U&E, LFT
• Biopsy of mass: cell type. Most commonly squamous cell carcinoma
• MRI pelvis: identify size of tumour
• CT CAP: look for nodes and METs – staging
– Treatment:
• Concurrent chemoradiotherapy: Cisplatin and 5FU
• Radical pelvic radiotherapy HDR brachytherapy: insert beta radiation pellets into vagina and surrounding
structures, emits high dose radiation to localised area. Highest risk of recurrence.
• Spreads: up into uterus - nothing to stop it, down into vagina – nothing to stop it. Not so much bladder
or rectum.
– Transition zone – glandular to squamous tissue where most cancers arise.
– Complications of chemo – toxic effect of endothelial cells
• Early (6w-3m): cystitis, haematuria, nausea, diarrhoea, MUCOSITIS, frequency, dysuria
• Late (>3m): haematuria, shrinkage of bladder, narrowing/stricturing of bowel/rectum – stoma, 2o
malignancies, infertility, PR bleeding, diarrhoea

50. Gynae Cancers
• Cervical Cancer
– HPV!!!! 6&11 – 90% of genital warts etc. 16&18: 70% cervical cancers, 50% vulval
cancers, 70% vaginal cancers, anal and head/neck cancers
– Locally spreads – vagina, uterus, parametrium
– Distant spread – pelvic/para aortic nodes, liver, lungs
– HPV vaccines: gardasil against HPV 6,11,16,18. girls aged 12-13. herd immunity would
be best. 3 injections over 6months.
– Cervical cancer screening has reduced the incidence and mortality by 80%
– 1/3 eligible women not screened
– Spreads locally until the later stages
– Treatment: chemoradiotherapy

51. Gynae Cancer
• Endometrial Cancer
– Presentation: post-menopausal bleeding
– Investigations: FBP, U&E, LFTs
• Vaginal US: best way to assess endometrium
• Pelvic MRI: staging. Nodes and spread
• Endometrial biopsy: cell type
– Treatment
• Simple hysterectomy for low grade
– 80% occur in post-menopausal women. As they aren’t meant to bleed picked up early.
Pre-menopausal harder to detect.
– RFs
• Obesity!!!!!!!
• Oestrogen as it drives endometrial proliferation
• Tamoxifen: breast antagonist but endometrial partial agonist
• Age
– Picked up at stage I survival 86%, stage II 66%, stage III 44%, stage IV 16%
– Majority present early when confined to uterus
– Hysterectomy is usually curative
– Pelvic radiotherapy improves local control in those with high grade disease, cervical
invasion or invasion of myometrium