Episode Thirteen: Cancer

  • Written & Researched By: Sarah Donnelly
  • Peer Review: Caleb Dusdal
    (cover art from unknown artist, apologies if this is yours, let us know and we’re happy to put your credit on it)

Objective One
In all patients, be opportunistic in giving cancer prevention advice (e.g., stop smoking, reduce unprotected sexual intercourse, prevent human papillomavirus infection), even when it is not the primary reason for the encounter.
Smoking
  1. https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/make-healthy-choices/live-smoke-free/smoking-shortens-lives/?region=on

Stop smoking – QuitNow provincial programs (BC, ALberta) that offer up to 12 weeks of smoking cessation tools, including medication, and nicotine replacement therapy

Why is this good?

-decrease risk of lung cancer, esophageal cancer, oropharyngeal cancers, and multiple others- On average, people who smoke live 10 years less than non-smokers.

HPV

HPV prevention – vaccine – gardasil 9 – protects against HPV 16+18 – two strains that cause > 70% cervical cancers and 7 others HPV strains that cause cervical cancers or genital warts. Reducing unprotected sexual intercourse can also lessen your risk of HPV exposure; however, oral sex and sex with barriers such as condoms still expose you to HPV

EtOH

NIH reports association between alcohol consumption and a number of Cancers, including:

  • Head and Neck Cancers including: Oral cavity, throat and larynx, with dose-dependent risk increases
  • Oesophageal Cancer, of the squamous cell variety
  • Liver Cancer, approximately a 2 fold increase in both Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma
  • Breast Cancer

Colorectal Cancer – moderate to heavy consumption carries 1.2-1.5 RR increase compared to no EtOH consumption

Skin Cancer

Advise of the risks of excess sun exposure. Advise to avoid direct sun during the middle of the day, use of mechanical sun cover is preferable, but at least sunscreen if not. Avoidance of tanning beds.
Unfortunately this is usually due to excess exposure when someone is younger, so try to give this advice to your younger patients as possible.
The Canadian Cancer Society recommends a few things:  https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/make-healthy-choices/be-sun-safe/the-6-best-ways-to-be-sun-safe/?region=on

  • Check the UV index, when it is above 3 you are at significantly greater risk
  • Reduce time in sun between 11am and 3pm (or any time of day when UV index > 3)
  • Seek shade
  • Clothes protect better than sunscreen, including large brimmed-hats
  • Get some cool shades – choose ones with UVA/UVB protection in wraparound style
  • Use sunscreen properly – SPF of at least 30 and use sunscreen along with the other measures above, no instead of
Objective Two
In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (e.g., with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing).

Cervical Cancer
  • WHY?
    • Can prevent up to 90% of cervical cancers with early intervention
  • WHEN?
  • Age 25-69 every 3 years (or starting at age 28 if you are not sexually active). *Should note that sexually active isn’t just penetrative intercourse and also includes touching, oral sex, or any genital to genital contact
  • After age 70, you can stop having Pap tests if:
  • Your last 3 tests, done within the past 10 years, were normal
  • You haven’t had any serious abnormal cell changes in the past
  • You had an HPV test result that was negative
Breast Cancer
  • WHY?
    • Find breast cancers early when treatment may be more effective
  • WHEN?
    • Ages 50-74 every 2 years
    • Ages 40-49 – done on an individual basis. Mammograms in this age group can cause more harm than benefit as false positives may lead to unnecessary interventions and physical/emotional harm
    • Age>75 – Benefit depends on personal health. For example, someone with a life expectancy of 1 year is unlikely to benefit from a mammogram
Colorectal Cancer
  • WHY? 
    • One of the most common cancers – affects 1/17 women and 1/14 men in their lifetime

WHEN?

  • 50-74 – screen with FIT/gFOBT q 1 year flex sigmoidoscopy q10years
    (of note this is q 2 years in BC and also q2y from the CTF recommendations).
    FIT/FOBT looks for occult blood in stool. If positive then move onto colonoscopy.
    • Of note, if someone comes in with rectal bleeding, do not do a FIT. FIT is only for screening. If you already know they are bleeding, you need a diagnostic test, such as a colonoscopy.
    • Also note that any iron deficiency anemia in men of any age and post-menopausal women is colon cause until proven otherwise.

May also expect guideline change at some point given increasing cases in younger populations. For example screening starts at age 45 in some places

Prostate Cancer

Screening for prostate cancer is done with a blood test for prostate specific antigen (PSA). PSA is controversial as it often leads to more harm than benefit due to unnecessary interventions. While prostate cancer is fairly common in men, most men diagnosed with it will not die of it since prostate cancers are fairly slow growing and not life threatening

WHEN
Current official Canadian Task Force recommendations are to NOT screen men of any age for prostate cancer with PSA testing.
However, the Canadian Urological Association does differ from this with a more nuanced approach, linked in the shownotes https://www.cua.org/system/files/Guidelines/4888.pdf

So, exam info you need is probably, NO screening. In real life, there is some contention and If a patient is interested in having a PSA you should start speaking about the risks and benefits with them at age 50.

This can also start at a younger age if they are in a more high risk population:

  • Having a father or brother who had prostate cancer before age 65.
  • Knowing that a gene change, such as BRCA, runs in your family.
Lung Cancer
  • WHY? 
    • The MOST common cause of cancer-related deaths in Canada. More than 85% are related to smoking tobacco.

WHEN?
Keep in mind, this is quite a recent change, and so won’t be available in all jurisdictions. However, we wanted to include it for completeness as it is recommended by the Canadian Task Force. https://canadiantaskforce.ca/wp-content/uploads/2016/06/clinician-summaryscreening-for-lung-cancer-1.pdf

  • For adults 55-74 with at least 30 pack year smoking history who either
    • Currently still smoke, or
    • Quit less than 15 years ago

The recommendation is to get Low Dose CT (LDCT) annually, up to three consecutive times

Objective Three
In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.)

Again, this seems straightforward and obvious, but patients are easily lost in the shuffle. Make sure you are being forwarded consults and progress notes from the Cancer Agency. This process is simplified in Alberta as consults and progress notes are usually uploaded to NetCare (a provincial patient database). If there is a significant change in prognosis or a new diagnosis, it can be helpful to meet with the patient to offer support and understanding.

Also, re-listen to episode 12, because we covered a number of resources available and recommendations for follow-up for your patient diagnosed with Cancer.

Objective Four
In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (e.g., family issues, loss of job), and the patient’s ability to cope with these consequences.

This seems very straight forward, but can easily be overlooked in the whirlwind of activity that comes with a new cancer diagnosis. It is easy for patients to feel powerless in the face of a new cancer diagnosis and listening and understanding what they are experiencing can make a large difference.

Additionally, cancer agencies generally have social workers who can help patients fill out disability forms and apply for other resources. In particular, pediatric cancer centres often have free counselling available for patients and parents. 
I hate to say this again, but we covered some great resources available to you and your patient for helping with these. Pop back there and give it a quick listen.

Objective Five
In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (e.g., diarrhea, feet paresthesias), as the patient may not volunteer this information.

We covered a number of these in episode 12: Breast Lump, so definitely go back and listen to that episode.

In the meantime, they have asked us specifically to cover diarrhea and lower limb parasthaesias. So….we will.

These are coming from the BC Cancer Symptom Management Guidelines.
http://www.bccancer.bc.ca/nursing-site/Documents/GuidelinesforManagementofCID.pdf

Chemotherapy-Induced-Diarrhea(CID)

The prevalence of this in chemo or radiation treated patients is estimated at 45% for those treated with irinotecan or 5-fluorouracil.
They offer a few risk factors which make this more likely to occur:

  • Older females
  • Lower performance status (ECOG 2 or more)
  • Existing bowel pathology: colitis, or lactose intolerance for ex
  • Tumour in the bowel
  • Weekly chemo, particularly irinotecan or 5FU
  • Previous chemotherapy-induced-diarrhea
  • Concomitant Abdo-pelvic radiation and chemo


They break this down into severity. Which is essentially mild/mod(grade 1-2) and severe(grades 3-4)

Grades 1-2 = 6 or fewer bm per day, with nocturnal stools and some abdo cramping

Grades 3-4 = more than 10 bm per day, +- blood stool and clinical need for parenteral fluid support. These patients need hospitalization.

For mild cases:

Of course, because you’re a good physician, you rule out other causes for their diarrhea. 

  • Medications: softeners, laxatives, antacids
  • Infection: C Diff or Candida
  • Partial bowel obstruction
  • Malabsorption
  • Faecal impaction
  • Acute radiation reaction
  • Diets high in fiber or lactose can aggravate diarrhea

Dietary Changes to Try

  • Increase intake of clear fluids: water, sport drinks, broth, gelatin, clear juices
  • Can consider a BRAT diet: banana, rice, apples, toast
  • Patients who get diarrhea after starting irinotecan specifically need pharmacologic intervention as dietary intervention alone will be inadequate

Skin Care

Recommend perianal skin hygiene. Use mild soap to cleanse area after bm and pat dry, do not rub.
Can consider sitz baths to soothe the area.

Can also consider barrier creams as needed.

Medications
– moderate(grade 2) diarrhea, or mild(grade 1) diarrhea that persists 12-24 hours needs pharmacologic intervention

  • Loperamide
    • 4mg, followed by 2mg q4h or after each unformed stool
    • Up to a max of 16mg per day
      If the diarrhea lasts longer than 24 hours
      • Loperamide dosing can be increased to 4mg to start
      • 2mg q2h and continued for 12 hours after resolution of the diarrhea and normal diet
  • Atrophine-diphenoxylate “Lomotil”
    • May be useful as adjunct to the loperamide for mild/moderate(grade 1-2) diarrhea
    • 1-2 tabs q6-8h
  • Octreotide
    For mild/mod (grade 1-2) diarrhea lasting more than 24 hours despite loperamide with/out atropine-diphenoxylate
    • 100-150 ug SC tid
    • For grades 3-4 diarrhea, with no improvement, this dose should be increased to 300-500ug SC tid
    • Can be discontinued 24 hours after cessation of diarrhea and normal diet
  • Antibiotics
    If concomitant neutropenia, antibiotics should be considered until diarrhea resolves, and granulocyte counts normalize
Objective Six
In patients with a distant history of cancer who present with new symptoms (e.g., shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis.

The Alberta Provincial Tumour Team has developed guidelines for follow-up care. While this is related to breast Cancer, the premise remains the same.

Some presentations or symptoms that they mention warranting extra consideration for someone with a history of Cancer, and the appropriate investigations are:

Objective Seven
 In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.)

If this is a new diagnosis, you will need some help from investigations. Likely a tissue biopsy to prove and identify the cancer. In addition you will need advice and expertise from your oncology colleague. 


As a frame of reference, we have included the serious illness conversation guidelines. Step three in this process is to “share the prognosis” and suggests framing it as 

“I want to share with you my understanding of where things are with your illness”

And if you’re unsure of the prognosis at that time, 

“I hope you will continue to live well for a long time, but I am worried you could get sick quickly”

For a more thorough discussion of this process, pop back to Episode 10: Bad News.

Let us know what you think!

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