Diagnosis and what happens after referral

Transcription

1 Diagnosis and what happens after referral Dr Kate Newbold Consultant in Clinical Oncology The Royal Marsden Women's cancers Breast cancer introduction 1

2 Treatment Modalities Early stage disease -larynx and naso/oro/hypopharynx: RT alone -oral cavity: surgery alone Advanced stage naso/oro/hypophrynx and larynx - organ preservation - radical chemoradiotherapy Advanced stage oral cavity/paranasal sinuses -primary surgery -adjuvant (chemo)radiotherapy

3 Early Stage disease Early Larynx -T1-2 N0 larynx -3.5 to 4 weeks of daily RT fractions Stage I-II naso/oro/hypopharynx - 6 weeks of daily RT alone - 30 fractions

4 Advanced Stage disease Stage III larynx -Induction chemotherapy and chemoradiotherapy Stage IV larynx -Laryngectomy Stage III-IV naso/oro/hypopharynx -Induction chemotherapy and chemoradiotherapy

5 5 The Royal Marsden Q: What is the 2 year survival rate for stage I-II head and neck cancer? 1. <20% 25% 25% 25% 25% % % 4. >70% <20% 20-50% 50-70% >70%

6 6 The Royal Marsden Q: What is the 2 year survival rate for stage III-IV head and neck cancer? 1. <20% 25% 25% 25% 25% % % 4. >70% <20% 20-50% 50-70% >70%

7 2 year survival rates (CRUK) Table 3.1: Stage and two-year crude survival, cancers of the oral cavity and pharynx, South and West of England, Oral cavity 2-year crude Pharynx 2-year crude No. of cases survival (CI) No. of cases survival (CI) % % All cases ( ) ( ) I Early disease ( ) ( ) II Locally advanced ( ) ( ) III Tumour in lymph nodes ( ) ( ) IV Metastatic ( ) ( ) Unknown ( ) ( )

8 Sequential induction chemotherapy followed by radical chemo-radiation in the treatment of locoregionally advanced head and neck cancer Bhide et al, BJC 2008 LC 72% at 2 years OS 63% at 2 years

9 2 year overall survival 86.7% 2 year PFS -Oral cavity 86% -Nasopharynx 94% -Oropharynx 84% -Pharyngolarynx 83% Radiotherapy and Oncology

10 Case study - Oropharynx 48 yr old accountant Presents with 2/12 history right sided otalgia Then noted right neck lump Married, non smoker, moderate alcohol, 2 children aged 10 and 12

11 11 The Royal Marsden Q: What would you do? 25% 25% 25% 25% A. Prescribe antibiotics B. Refer non-urgently for imaging C. Refer under 2ww D. Reassure A. B. C. D.

12 12 The Royal Marsden Q: If this patient was a smoker, would this have affected your decision? A. Yes B. No 50% 50% A. B.

13 Case study - Oropharynx The patient was prescribed antibiotics which showed no improvement, and was then referred. After investigation, it was discovered they had pct2 cn2b cm0 SCC p16+ right tonsil/base of tongue.

14 14 The Royal Marsden Q: What treatment option should be taken? A. Surgery 25% 25% 25% 25% B. Induction chemo followed by chemoradiation C. Chemoradiation D. Chemotherapy A. B. C. D.

15 Induction Chemotherapy Blanchard, P., et al., J Clin Oncol, (23): p Tax-PF was associated with significant reductions of progression, locoregional failure, and distant failure compared with PF, with HRs of 0.78 (95% CI, 0.69 to 0.87; P <.001), 0.79 (95% CI, 0.66 to 0.94; P =.007), and 0.63 (95% CI, 0.45 to 0.89; P =.009) respectively Currently for locally advanced disease T4 and/or N2B

16 Induction chemotherapy Evidence for chemotherapy in addition to radiotherapy in patients 70 years 2 x 21 day cycles of induction chemotherapy -Taxotere (75 mg/m2) day 1, Cisplatin (75 mg/m2) day1 and 5- Fluorouracil (750 mg/m2) days days inpatient -SEs: myelosuppression nausea and vomiting hair loss neuropathy tinnitus/hearing loss nephrotoxicity fertility Consider ambulatory in appropriate cases

17 Oropharynx 48 yr old professional Presents with 2/12 history right sided otalgia Then noted right neck lump Received antibx initially with no improvement Married, non smoker, moderate alcohol, ct2 cn2b cm0 SCC p16+ right tonsil/base of tongue

18 Delineation of Prognostic Groups

19 Chemoradiotherapy 6 weeks, 30 fractions OP treatment, mon fri Concomitant cisplatin chemo Day 1 and 29 of radiotherapy. Overnight stay

20 Preparation for chemoradiotherapy Women's cancers Breast cancer introduction 20

21 21 The Royal Marsden Q: Why do we perform dental assessment before radical radiotherapy? 25% 25% 25% 25% A. To make radiotherapy delivery easier B. To improve radiation dose homogeneity C. To reduce risk of osteoradionecrosis D. To reduce risk of infection A. B. C. D.

22 Preparation for Chemoradiotherapy (1) Dental assessment -RT causes xerostomia -RT reduces vasculaity of mandible Aim to prevent osteoradionecrosis Require OPG and review by oral surgeon/restorative dentist At least 14 days required between extractions and start RT

23 23 The Royal Marsden Q: Which should patients stop during treatment? A. Alcohol 25% 25% 25% 25% B. Smoking C. Dairy products D. Red meat A. B. C. D.

24 Preparation for Chemoradiotherapy (2) Nutrition -dietetic review -risk of re-feeding syndrome -degree of poor/malnutrition Alcohol -assess for risk of withdrawal Smoking -reduces rate of cure by 30% -increases treatment induced toxicty -offer cessation advice and help in conjunction with GP

25 Preparation for Chemoradiotherapy (3) Renal function -EDTA or Cockcroft calculation -GFR >60ml/min proceed with cisplatin -GFR <60ml/min consider carboplatin or cetuximab Hearing -if reduced hearing or pre-existing tinnitus -consider switching cisplatin to carboplatin or cetuximab

26 Preparation for Chemoradiotherapy (4) If cardiac pacemaker or implantable defibrillator - needs review by cardiac technologists -may need daily monitoring during treatment

27 Radiotherapy Planning Women's cancers Breast cancer introduction 27

28 Mould Room

29 Set-up on LINAC

30 Treatment planning

31 CT planning - 3D Reconstruction

32 CT Planning - dose calculation

33 Intensity-Modulated Radiotherapy (IMRT) Women's cancers Breast cancer introduction 33

34 What is Intensity Modulated Radiotherapy? Tumour Dose Conventional Radiotherapy Tissue Intensity Modulated Radiotherapy

35

36 Treatment planning

37 Linear Accelerator

38 Toxicity of radiotherapy normal tissue tolerance depends on total volume irradiated total dose fractionation schedule ie size of each fraction, number of fractions, duration of treatment previous surgery co-existing problems eg smoking, drinking, chronic disease

39 Toxicity of radiotherapy Early -2-3 weeks into treatment -reversible - settle within 4-6 weeks of completion of treatment -present to some degree in all patients -severity does not predict for late toxicity Late -6-9 months post RT -tends to be permanent, may be progressive -5-10% of patients will develop severe toxicity

40 Toxicity of radiotherapy early Skin erythema dry desquamation moist desquamation hair loss

41 Toxicity of Radiotherapy- early Mucous membranes loss of taste, dry mouth, dysphagia, mucositis

42 Loss of taste Damage to the circumvallate and fungiform papillae after 20Gy Bitter/sour affected more than sweet/salty Partial/complete recovery is usual but recovery can be slow

43 Xerostomia Major salivary glands produce 90% saliva Parotid gland often in irradiated volume The serous acini are more sensitive than the mucous acini, resulting in production of thick saliva Change in oral flora

44 Toxicity - late Skin -alopecia -oedema / fibrosis -Depigmentation Salivary glands -Xerostomia Dental Hearing -EAM -Middle ear -Cochlea Spinal cord -Lhermittes synd -Myelitis

45 Late Toxicity -Skin/Soft tissues

46 Osteoradionecrosis Occurs in the mandible Hypoxia and hypovascularity Related to Total dose Dose/# Brachytherapy Chemotherapy?

47 47 The Royal Marsden Q: Do breaks or gaps in radiotherapy: 25% 25% 25% 25% A. Reduce overall survival B. Reduce local control C. Reduce acute toxicity D. Reduce late toxicity A. B. C. D.

48 Importance of Overall Time of Treatment Decreased tumour control probability (TCP) when same dose is delivered over longer time Need to deliver higher dose to maintain TCP if treatment duration prolonged Explained by rapid repopulation in response to clonogenic cell depletion during RT

49 K. Kian Ang, 2001: Interval between Surgery and PORT

50 K. Kian Ang, 2001: Cumulative time of combined modality

51 Conclusion The Challenge -advanced disease -function preservation, cosmesis -proximity of critical structures -compliance -nutrition

52 MDT ENT Maxillo-Facial Plastics Restorative Dentists Clinical Oncologists Palliative Care Radiologists Histopathologists Cytopathologists Psychologist/psychiatrist SALT Dietitians Clinical Nurse Specialists Research Nurses Social Worker Physicists Radiographers Prosthetics Primary Care