Chapter 10: Oncology

Cancer Diagnosis and Registration 

  • Cancer is unregulated cell division with metastatic potential.
  • In general, there are two broad groups of cancers: solid and haematological malignancies.
  • Solid malignancies include carcinomas, Melanomas, and sarcomas, which can affect any part of the body. Haematological malignancies include lymphomas, leukemia, and Multiple Myeloma.
  • The etiology for cancer is multifactorial: environmental and intrinsic.
  • Risk factors include infections, tobacco smoking, age, chemicals, toxins, genetic predisposition, and radiation exposure.
  • General cancer prevention strategies need to target risk factors. Cancer screening includes Cervical cancer screening using VIA or pap-smear, Mammography, fecal occult blood with supporting colonoscopy, upper gastro-intestinal endoscopy in high-risk cases for instance those with reflux disease, screening and treatment of premalignant skin lesions in those at risk (e.g. people with Albinism).
  • Malawi National Cancer Registry pools data from hospital-based cancer registries, KCH, Zomba and Mzuzu Central Hospitals for epidemiology and surveillance. There is also a population-based cancer registry at QECH.

General Clinical Features 

SIGNS AND SYMPTOMS

  • Initial presentation depends on the system involved and may include a mass which may or may not be painful and ulcerated.
  • GIT tumours may cause difficulties and pain when swallowing, change in bowel habit, abdominal distension.
  • Genitourinary tumours: abnormal vaginal discharge and bleeding (spotting, heavy, contact), hematuria.
  • Cutaneous malignancies: pigmented skin lesions, limb edema
  • Metastatic tumours: back or bone pain, paralysis, fractured limb, headache and seizures.
  • Cachexia, recurrent fevers, unexplained weight loss and night sweats may occur with advanced disease or leukemia.
  • Cancers involving skin: ulcer with irregular edges, easily bleeds, necrotic.
  • For a cancerous mass; it could mobile or fixed, pigmented, exophytic or endophytic with contact bleeding.
  • Lymphadenopathy
  • Intraabdominal spread may cause palpable mass, ascites, bowel obstruction, jaundice, nodular/irregular hard prostate on DRE.
  • Limb involvement causing woody hard edema with or without ulceration, limb swelling due to lymphatic obstruction.

GENERAL INVESTIGATIONS

Laboratory tests:

  • Full blood count – persistently elevated or decreased parameters in any of the blood cell lines should raise suspicion of a malignancy.
  • Bcr-Abl detected on PCR if Leukaemia suspected.
  • Tumour markers -elevated titers of beta-HCG, CEA, AFP, CA-125, PSA, CA 19-9, CA 15-3 and LDH may suggest a particular cancer. Tumour markers may also be used to monitor response to cancer treatment. Caution when interpreting as many are non-specific; need to correlate with the clinical picture and assays used.
  • Fecal occult blood.

Radiological tests:

  • Mammography and Ultrasound for breast cancer.
  • X-rays (Chest/Bone) for detection of primary cancer or metastases.
  • Scanning (Ultrasound scan/Computed Tomography/Magnetic Resonance Imaging/Bone Scan/PET-CT) investigating particular sites for cancer involvement and the extent.

Haematology, Cytology, Histology:

  • Peripheral blood smear in haematological cancers
  • Cytology to assess cancer cells: this examines fluids suspected to be involved with cancer or needle aspirates from cancer masses
  • Histology for solid tumors: core biopsy, incision, excision, surgical specimen
  • Bone marrow aspirate and trephine biopsy
  • Immunohistochemistry: various stains available depending on cancer suspected.

Tests to undertake when specific turmuors are suspected:

  • Cervical cancer: punch biopsy for histology.
  • Prostate cancer: Transrectal ultrasound guided prostate biopsy (12 core biopsy is the standard; 6 from each lobe) and PSA. Fusion biopsies are not routinely done in the country at the moment.
  • HIV test; HIV-related cancers (KS, cervical cancer, lymphoma) are suspected or diagnosed
  • Barium swallow, gastroscopy and tissue biopsy for oesophagus or gastric cancer
  • Breast cancer: Breast USS, Mammography, biopsy including immunohistochemistry
  • Colon cancer: Fecal occult blood, colonoscopy and biopsy
  • Lung cancer: Sputum cytology, bronchoscopic, mediastinal or CT-guided biopsy
  • Bladder cancer: Cystoscopy, Urine cytology and Trans-urethral resection of bladder tumour with detrusor muscle biopsy represented in the specimen
  • Hepatocellular carcinoma: Baseline INR, CT abdomen +/- biopsy, AFP, Hepatitis B and C tests

General Treatment Measures 

GENERAL MEASURES 

  • Treatment for cancers involves a multidisciplinary approach with multiple modalities.
  • These include surgery, radiation, laser therapy, systemic therapies (such as chemotherapy, hormonal therapy, immunotherapy and targeted therapy) and palliative care.
  • Most of the advanced cancers require all the treatment modalities.
  • There is evidence to support better outcomes if cancer cases are managed in specialized centres.

Treatment options depend on:

  • Stage of disease at presentation
  • Histological type of cancer
  • Age of the patient

Factors to consider before each treatment

  • Patient's preference
  • Availability and cost of treatment as well as expertise on the ground
  • Co-morbid conditions (hypertension, DM, COPD, cardiovascular, renal and liver conditions)
  • Performance status (general condition of the patient) assessed using WHO, ECOG, Karnofsky scores.
  • Age of patient
  • Organ function (haematological, liver, renal, cardiorespiratory)
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