Module 2:

Introduction to Cancer Care Continuum

LEE KAH YEE

Senior Clinical Psychologist

M.ClinPsych (UCSI), B. Soc. Sci. (Hons) Psych (TAR UMT),
Dip. Soc. Sci. (Counseling) (TAR UMT)
Module 2:
Introduction to Cancer Care Continuum

2.1 Basic Cancer Terminology

2.2 Understanding the Cancer Continuum
Learning Objectives

1. To identify basic cancer terminology in oncology setting.

2. To identify components of the cancer care continuum.
 2.1
Overview of Cancer
Basic Cancer
Terminology
What Is Cancer And Oncology?

Coined by Hippocrates Coined by Galen

Greek – karkinos (carcinos) = Greek – oncos = swelling

CRAB (referring to all tumours)

Why? – “cut surface of the Malignant ones called carcinos

malignant tumor with veins
stretched on all sides like a crab Suffix – oma – denotes
has its feet” cancerous lesions
What Is Cancer?

• Uncontrolled growth of abnormal cells

that divide and invade others within a
person’s body.

• Everybody has millions of cells that

grow, divide, make new cells and then
die – controlled.

• Cells that don’t follow control, abnormal,

start to grow out of control – don’t die
when required – multiplies out of control
= CANCER
 Hyperplasia, Metaplasia, Dysplasia, Neoplasia
• Normal cells can undergo hyperplasia OR dysplasia – then progress to become cancer cells
Tumors – Benign And Malignant

Tumors
Abnormal mass or group of cells
Benign Malignant
● Non cancerous ● Cancerous

● Don’t grow into other tissue ● Grow into other tissues

(invasive)

● Spread to other parts of the

body (metastasis)
The 4 Main Groups Of Cancer
Staging of Cancer
Staging Of Cancer
• Staging – assessing the extent of spread of the cancer

Stage 1 : Local disease - Tumour is small and has

not grown outside the organ it started in.

Stage 2 : Invasion - Tumour is larger than stage

1 but has not spread to nearby tissues.

Stage 3 : Regional Disease - Tumour is large and has

spread to nearby tissues and lymph nodes.

Stage 4 : Metastasis - Tumour has spread through the

blood or lymphatic system to a distant site in the body.
 Staging Of Cancer - Breast Cancer
Stage Characteristics Localisation

Stage 0 Ductal carcinoma in situ (DCIS) A non-invasive pre-cancerous

change

Stage 1 The cancer is small and only found in your breast with no or Early breast cancer
only microscopic involvement of lymph nodes in your armpit

Stage 2 The cancer is larger than in stage 1 and / or is found in just a Early breast cancer
few nearby lymph nodes

Stage 3 The cancer is larger than in stage 2, or involves the skin of the Locally advanced breast cancer
breast, or the chest wall, or is a type of breast cancer called
inflammatory breast cancer, and / or has spread from the breast
to more than just a few lymph nodes close to the breast

Stage 4 The cancer has spread to other parts of your body Advanced breast cancer
Staging of Cancer (TNM STAGING)
 2.2
Understanding the
Cancer Continuum
The Cancer Care Continuum
Risk Factor
 Risk Factors
Modifiable Risk Factors Non – Modifiable Risk Factors

• Alcohol • Age

• Tobacco • Family History

• Diet • Gender

• Radiation

• Sunlight
Other Risk Factors
• Obesity
• Chronic Inflammation
• Carcinogens
• Immunosuppression
• Infectious agents
• Hormones
• Physical activity
Screening and Diagnostic
Tests
Understanding Signs And Symptoms

Signs VS Symptoms

Any objective, visible Definition Any subjective, non-visible

evidence from the disease. evidence from the disease

Blood coming out of Example Anxiety, low back pain, and

nostrils; it is apparent to the fatigue; only the patient can
patient, physician, and perceive them
others
Screening And Early Detection

Screening VS Early Detection

Looks for early signs of Definition Rapid diagnosis of a patient

cancer in people without as soon as symptoms
symptoms appear

Screening tests Test used Diagnostic tests

Detect abnormalities Function Confirms a cancer diagnosis

Understanding Signs And Symptom, Screening And
Early Detection
 Screening Test And Diagnostic Tests

Screening tests Diagnostic Tests

Purpose To detect potential disease indicators To establish the presence / absence of disease

Target Population Large numbers of asymptomatic, but potentially at risk Symptomatic individuals to establish diagnosis, or
individuals asymptomatic individuals with a positive screening test

Test Method Simple, acceptable to patients and staff Maybe invasive, expensive but justifiable as necessary to
establish diagnosis

Positive Results Generally chosen towards high sensitivity not to miss Chosen towards high specificity (true negatives). More
Threshold potential disease weight given to accuracy and precision than to patient
acceptability
Positive Results Essentially indicates suspicion of disease (often used Result provides a definite diagnosis
in combination with other risk factors) that warrants
confirmation

Cost Cheap, benefits should justify the costs since large Higher costs associated with diagnostic test maybe
number of people will need to be screened to identify justified to establish diagnosis.
a small number of potential cases
Cancer Screening And Diagnostic Tests

Type of cancer Screening Tests Diagnostic Tests

Breast Cancer Mammogram US-guided Biopsy

Ultrasound Surgical biopsy
Clinical Breast Examination FNAC
Breast Self-Examination
MRI
CT

Cervical cancer Pap smear Colposcopy + Biopsy

Liquid based cytology (LBC) (Curative)
HPV DNA
Cancer Screening And Diagnostic Tests

Type of cancer Screening Tests Diagnostic Tests

Colorectal Cancer FOBT (guaiac) Colonoscopy + Biopsy

i-FOBT (Curative)
Stool DNA
Colonoscopy
Sigmoidoscopy
CT Colon

Lung Cancer Low-dose CT scan Bronchoscopy/EBUS + Biopsy

Surgical Biopsy
Needle biopsy
Prostate Cancer PSA Transrectal biopsy/Transperineal
DRE biopsy
Multiparametric MRI Surgical Biopsy
Diagnostic Tests
In most situations, a biopsy is the
only way to definitively diagnose
cancer.

From the biopsy, you will get a

sample of cells – these are
examined under a microscope.

Normal cells can be distinguished

from cancer cells and the type of
cells which make up the cancer can
then be identified.
Staging
Staging The Cancer

● Need to know how much cancer there is, what it is, and where
it is to help determine the best treatment options.

● A cancer’s stage can also be used to help predict the course it

will likely take, as well as how likely it is that treatment will be
successful.

● Cancers of the same type and stage tend to have similar

outlooks, although each person is unique.
Staging The Cancer

3 main things need to be done:

• A biopsy often is needed to confirm a

cancer diagnosis

• Lab tests of cancer cells (from a

biopsy or surgery) and blood tests can
also be used to help stage some types
of cancer.

• Imaging tests like x-ray, CT scans,

MRIs, ultrasound, and PET scans may
also give information about how much
and where cancer is in the body.
 Lab Tests To Diagnose Cancer

Lab Test Characteristics

Histochemical stains Chemical dyes which are attracted to certain substances in different types of cancer cells

Immunohistochemical Use antibody / antigen – specific lock / key mechanism. there is color change for each specific
stains antibody and antigen reaction

Electron microscope Uses very high magnification (1000x normal light microscope) for certain intracellular
structures within cancer cells to identify the cancer

Flow cytometry Test cells from bone marrow, lymph nodes, for leukemia and lymphoma, then treated with
special antibodies (that stick to only certain types of cells with the antigens that can fit it),
then passed in front of a laser – if antibodies are present, the laser will give off a light that
can be detected.

Image cytometry Test cells using dyes reacting with DNA, analyse using digital camera and a computer

Cytogenetics Genetics of the cancer cell itself – recognizing abnormal chromosomes – Used to identify
lymphomas, leukemias and sarcomas
 Cont’d

Lab Test Characteristics

FISH – Flourescent in Uses dyes linked to DNA that attach to specific parts of certain chromosomes
situ hybridization Can identify if certain targeted drugs can help cancer patients – HER2 gene expression

Molecular genetic Helps in finding some translocations too small to be seen in cytogenetic testing, identify
tests mutations in certain areas of DNA, identify antigen receptors on lymphocytes (for
lymphomas)

Tests include:
● RT – PCR : finds specific DNA sequencing that occurs in some cancers,
● Gene expression microarrays : compare hundreds of different RNAs – see which gene in
a tumour is active, to predict prognosis, can also be used to detect unknown primary
cancer.
● DNA sequencing : good for specific mutations and allow targeting of drugs, personalized
oncology, also can be used to identify those who have inherited certain genetic
mutations.
 Imaging Test
To stage a cancer, some of the commonly used
Test are recommended depending on:
imaging tests are:
• Where the tumor is and what type it is. Some
1) CT scan
imaging tests work better for certain parts of
the body.
2) MRI
• Whether or not a biopsy (tissue sample) is
3) Nuclear medicine scans – PET scan, thyroid
needed.
scans, bone scans, gallium scans
• Your age, gender, and overall health.

• The balance between any risks or side effects

and the expected benefits.

• Preference

• Cost
 Imaging Test : CT scan
• Shows tumor shape, size, location and blood vessels feeding the
tumour

• Uses thin focused beam to create pictures from multiple angles

• This together makes a picture showing a slice of a certain area of the

body

• Can use contrast (swallowed / injected / enema) to get a clearer

picture

• When you layer the slices together, you get a 3D view which can be
rotated on the computer to see all the different angles

• CT takes about 10 – 30 minutes

• For staging, usually a CT Thorax, abdomen and pelvis (CT TAP) is

done
Imaging Test : CT Scan
Imaging Test : CT Scan
 Imaging Test : MRI
• No radiation

• Uses magnets to make images

• Takes slices / views from many angles

• Can create pictures of soft tissue body parts which are hard to see in
other imaging tests

• Good for the brain

• Can use contrast to see brain and spinal tumours

• MRI machine is a long tube with a strong magnet. Patients slide into
the magnetic field created and radiowaves used to pick up signals
from Hydrogen atoms and convert them into pictures

• Takes about 1 – 2 hours

Imaging Test : MRI
Imaging Test : MRI
 Imaging Test : CT vs MRI
CT MRI
Image created within a few seconds, Show cancers CT cannot detect
effective for surveying the entire body (Prostate cancer, Uterine Cancer and liver
cancers)
Usually 1st choice for staging cancer
Brain and bone are also better to visualize
by MRI
Uses ionizing radiation- and thus could NO radiation
damage DNA – increase
Longer to do- sometimes up to 2 hours
Patient can become claustrophobic and
distressed by sound- need to sedate
Cannot/difficult for individuals with
pacemaker or other devices
 Imaging Test : Nuclear Medicine Scans
• Makes pictures based on body’s chemistry unlike CT / MRI

• Use liquid substances called radionuclides / tracers /

radiopharmaceuticals

• Cancer absorbs more / less of the tracer than normal tissue – special
cameras are used to create pictures showing where the tracer travels
and where it collects

• Cancer will show up as a hot spot or a cold spot (depending on the

type of scan being done)

• Radionuclides are injected and then after 2 hours the scan is done

• Scans usually takes about 1 hour

• Gallium scans radionuclides must be taken a few days before

 Imaging Test : Nuclear Medicine Scans
• Bone scans

• Bone scans look for metastasis to the bones.

They can often find bone changes much earlier
than regular x-rays. The tracer collects in the
bone over a few hours, then the scans are
done.

• Positron emission tomography (PET) scans

• PET scans usually use a form of radioactive

sugar (called fluorodeoxyglucose or FDG).
Body cells take in different amounts of the
sugar, and cancer cells, which are quick
growing, take up large amounts of FDG
Imaging Test : Nuclear Medicine Scans
 Imaging Test : Nuclear Medicine Scans
• Thyroid scans

• Used as both diagnostic and curative. Can be

used to find thyroid cancers as well as treat it.
Radioactive iodine (iodine-123 or iodine-131)
is swallowed. It goes into the blood stream
and collects in the thyroid gland.

• Gallium scans

• Gallium-67 is the tracer used in this test to

look for cancer in certain organs. It can also be
used for a whole body scan. The scanner looks
for places where the gallium has collected in
the body. Very helpful in lymphomas.
Treatment
Treatment

Cancer Treatment Options

Hormone Surgery Chemo Targeted

Therapy therapy therapy

Radiation Immuno Bone marrow transplantation

therapy therapy
 Treatment : Local VS Systemic

Local treatment Systemic treatment

● Only affects one part of the body ● Drugs that travel throughout the body,
killing metastatic cancer cells that have
● This includes surgery – removing tumour metastasized to other parts of the body far
from one part and radiotherapy – aimed at from the original
a certain area of the body to kill / damage
cancer cells ● Includes standard chemotherapy, targeted
therapy, immunotherapy, hormone therapy
Treatment : Surgery
• Surgery remains the gold standard for curative treatment.

• Aim to remove the tumour mass completely.

• In conjunction with chemotherapy and radiotherapy

• Sometimes, done as part of the diagnosis (surgical biopsy)

• Sometimes done also as part of staging – after opening up, search to see how far it has spread
in terms of lymph nodes / surrounding area (staging surgery)

• Sometimes done to remove some of the cancer (debulking surgery)

• Done when the tumour is obstructing but cannot totally remove because danger to
surrounding organs

• In advanced cancer, used to correct discomfort / disability to patients such as when abdominal
cancers cause intestinal obstruction, also to treat pain (palliative surgery)
Treatment : Surgery
• Side effects of surgery includes:

• Bleeding

• Blood clots

• Damage to nearby tissues

• Drug reactions

• Damage to other organs

• Pain

• Infections

• Slow recovery of other body functions

Treatment : Radiosurgery

• Radiosurgery is actually a radiation technique using

stereotactic radiation therapy

• Very focused, precise directed radiation therapy

• Like a ‘knife’ – that’s why called Gamma Knife

and CyberKnife

• By using radiation sources from different angles,

stereotactic radiation therapy delivers a large
precise radiation dose to a small tumor area

• The brain is the most common site that can be

treated using this technique, but its also used on
some head, neck, lung, spine and other tumours
 Treatment : Chemotherapy
• Chemotherapy is any treatment using chemicals / pharmaceuticals

• Nowadays, it has become common for chemotherapy to mean traditional / standard chemotherapy

• WHILE targeted therapy, hormone therapy and immunotherapy are considered other treatments

• In actuality, these are all CHEMOTHERAPY

• Chemotherapy is used for 3 main reasons:

Curative Control Palliation

Kill all the cancer cells and the cancer Shrink tumours / stop the cancer Ease symptoms caused by cancer
does not come back from growing / spreading –
people can feel better and live
longer - now we speak of
managing and controlling it as a
chronic disease
Treatment : Chemotherapy

• How is it used?

• To shrink a tumour before surgery or radiation therapy (neoadjuvant therapy)

• After surgery or radiation therapy to help kill any remaining cancer cells in the
body (adjuvant therapy)

• Together with other systemic treatments such as targeted therapy drugs that act
on certain targets of cancer cells; or immunotherapy drugs that help the immune
system fight cancer (combined action)

• With other treatments if cancer comes back or doesn’t completely go away

(recurrent therapy)
Treatment : Chemotherapy Issues
What drug to use?

• The type and subtype of cancer What dose to use?

• The stage of cancer (how far • Based on body weight What schedule to use?
spread) in kilogram OR
• Cycle = dose of 1 or
• Results of other tests on the • Based on body surface more drugs on 1 or
tumour such as biomarkers area more days then few
days or weeks
• Patient’s age • Doses differ for children without treatment
and elderly
• Patient’s overall health and current • Aim to maximise
medications • Also adjusted for those anti-cancer effect
with kidney / liver while minimizing side
• Other serious health problems disease and those who effects
cannot tolerate chemo
• Type of cancer treatment given in or those with low blood
the past counts
Treatment : Chemotherapy Side Effects
• Fatigue • Mouth, tongue and throat
The normal cells most likely to be
problems such as sores and
damaged by chemo are:
• Hair loss pain with swallowing
● Blood – forming cells in the bone
marrow
• Easy bruising and bleeding • Peripheral neuropathy or
● Hair follicles
other nerve problems
● Cells in the mouth, digestive tract,
• Infection (numbness, tingling)
and reproductive system
● Some chemo drugs can damage cells
• Anemia (low red blood cell • Skin and nail changes
in the heart, kidneys, bladder, lungs
counts)
and nervous system
• Weight changes
• Nausea and vomiting
● Side effects are usually minimal • Mood changes
● Most peope tolerates chemo very well, • Appetite changes
with NO side effects • Chemo brain (affecting focus
● Mild-moderate side effects can be • Constipation and concentration)
managed with simple medications only
• Diarrhea • Fertility problems

• Kidney problems • Urine and bladder changes

Treatment : Targeted Therapy
• Targeted therapy is a type of cancer treatment that uses drugs or other substances to
precisely identify and attack certain types of cancer cells

• Can be used by itself or in combination with other treatments, such as traditional or

standard chemotherapy, surgery or radiation therapy.

• Cancer cells typically have changes in their genes that make them different from
normal cells.

• Genes are part of a cell’s DNA that tell the cell to do certain things.

• When a cell has a certain gene changes, it doesn’t behave like a normal cell. For
example, gene changes in cancer cells might allow the cell to grow and divide very
quickly. These types of changes are what make it a cancer cell.
Treatment : Targeted Therapy
Treatment : How Does Targeted Therapy Work?

The action of targeted drugs can work to:

• Block or turn off chemical signals that tell the

cancer cell to grow and divide

• Change proteins within the cancer cells so the

cells die

• Stop making new blood vessels to feed the

cancer cells

• Trigger your immune system to kill the cancer

cells

• Carry toxins to the cancer cells to kill them,

but not normal cells
Treatment : Example Of Targeted Therapy
Treatment : Types Of Targeted Therapy
Treatment : Side Effects Of Targeted Therapy

• Skin problems • Changes in hair or skin color

• Rash • Changes in and around the eyes

• Dry skin

• Photosensitivity

• Itching

• Red, sore cuticles (area around nails)

• Hand foot syndrome

Treatment : Immunotherapy

Immunotherapy is treatment that uses certain parts of a person’s immune

system to fight diseases such as cancer.

Methods used includes:

• Stimulating, or boosting, the natural defenses of your immune system so
it works harder or smarter to find and attack cancer cells

• Making substances in a lab that are just like immune system components
and using them to help restore or improve how your immune system
works to find and attack cancer cells
Treatment : Immunotherapy Types
Treatment : Immunotherapy Side Effects
▪ Fever ▪ Allergic reactions during the infusion CNS ISSUES
▪ Chills ▪ Abnormal levels of minerals in the
▪ Weakness blood, such as low potassium, ▪ Headaches
▪ Headache sodium, or phosphorous levels ▪ Changes in
▪ Nausea ▪ A weakened immune system, with an consciousness
▪ Vomiting increased risk of serious infections ▪ Confusion or agitation
▪ Diarrhea ▪ Low blood cell counts, which can ▪ Seizures
▪ Low blood increase the risk of infections, fatigue, ▪ Shaking or twitching
pressure and bruising or bleeding (tremors)
▪ Rashes ▪ Autoimmune reactions ▪ Trouble speaking and
understanding
▪ Loss of balance
Differences Of Treatment : Systemic
Treatment : Radiation
• Radiation therapy uses high-energy particles or waves, such as x-rays, gamma
rays, electron beams, or protons, to destroy or damage cancer cells.

• Radiation works by making small breaks in the DNA inside cells. These breaks
keep cancer cells from growing and dividing and cause them to die. Nearby
normal cells can also be affected by radiation, but most recover
 TREATMENT : RADIATION (GOALS)
1. Cure or shrink early stage cancer
1. Cure
Radiation or shrink
may be usedearly stage
by itself cancer
in these cases to make the cancer shrink or completely go away. Radiation
Some cancers are very sensitive to radiation.
therapy can be used before chemotherapy or other Radiation may be
anti-cancer usedOR
drugs by pre
itselfsurgery
in these
tocases
shrinktothe
make the(this is
tumor
cancer
called shrink or completely
pre-operative therapy orgoneoadjuvant
away. In some cases,OR
therapy) chemotherapy
post surgeryortoother
help anti-cancer drugsfrom
keep the cancer maycoming
be given
back
first. For
(called other cancers,
adjuvant therapy).radiation may be used before surgery to shrink the tumor (this is called pre-operative
therapy or neoadjuvant therapy), or after surgery to help keep the cancer from coming back (called adjuvant
2.therapy).
Stop cancer from recurring somewhere else
Cancer can spread from where it started to other body parts. Sometimes, radiation to prevent future cancer can be
2. Stop
given cancer
at the samefrom
time recurring somewhere
that radiation is given toelse
treat existing cancer, especially if the area the cancer might
Cancer
spread to can spread
is close from
to the where
tumor it started to other body parts. Doctors often assume that a few cancer cells
itself.
might already have spread even when they can’t be seen on imaging scans like CT scans or MRIs. In some
3.cases,
Treatthe area where
symptoms the cancer
caused most often
by advanced spreads to may be treated with radiation to kill any cancer cells
cancer
before they
Sometimes grow has
cancer into spread
tumors.too much to be cured. But some of these tumors can be shrunk to relieve problems
like pain, trouble swallowing or breathing, or bowel blockages
Sometimes, radiation to prevent future cancer can be given at the same time that radiation is given to treat
4.existing cancer,
To treat especially
cancer that hasif returned
the area the cancer might spread to is close to the tumor itself.
If a person's cancer has returned (recurred), radiation might be used to treat the cancer or to treat symptoms
caused by advanced cancer.
Treatment : Radiation Types
● External radiation (or external beam
radiation): uses a machine that directs
high-energy rays from outside the body
into the tumor. It’s done during
outpatient visits to a hospital or
treatment center. It's usually given over
many weeks and sometimes will be
given twice a day for several weeks.

● Internal radiation: Internal radiation is

also called brachytherapy. A radioactive
source is put inside the body into or near
the tumor.

● Systemic radiation: Radioactive drugs

given by mouth or put into a vein are
used to treat certain types of cancer.