General strategies of Cancer Treatment and evaluation of Response

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Presentation transcript:

General strategies of Cancer Treatment and evaluation of Response Lodovico Balducci M.D. Senior Member Emeritus Moffitt Cancer Center Tampa, FL

Clinical Case 83 year old man with cough CT chest reveals a 3 cm mass Left Lower Lobe Biopsy reveals an adenocarcinoma primary lung PS 1; Lives alone, Independent ADL IADL

Clinical Case ROS: osteoarthritis, type II DM PMH: MI age 65: CABPG; quit smoking Colon cancer stage II age 71; surgery Fracture right tibia age 19 Appendectomy age 41

Clinical case HB 13.8; Ca 10.1 Physical exam: Lung moving 3 cm bilaterally Deformity Left knee Overweight

Strategy of cancer treatment Effectiveness Toxicity Patient Life expectancy Treatment tolerance Goals CLINICAL DECISIONS Cancer Stage Aggressiveness Treatment Sensitivity Tumor sanctuary

What do we want to know Stage: PET scan; CT scan, MRI Sensitivity to treatment: EGFR mutation Ros Mutation ALK mutation RAS mutation PDL1

What will we do with the information Local disease: surgery; radiosurgery, ablation Metastatic disease: systemic treatment according to sensitivity Loco-regional disease: combination of local and systemic treatment Brain metastases: may add radiation

Forms of cancer treatment Loco-regional treatment Systemic treatment Surgery Radiation Therapy Loco-regional infusions Local ablation Hormonal therapy Cytotoxic chemotherapy Targeted therapy Immune check-point inhibitors Vaccines Radio-isotopes

Examples of tumor markers Lung: Ras, Ros, EGFR, ALK Breast: hormone receptors, HER, Brca Colorectal: Ras, MSI All MSI?

New techniques to assess cancer Circulating tumor cells Liquid biosy Molecular response in hematological malignancies

Adjuvant and neoadjuvant treatment 65 year old woman with a 2 cm tumor of the left breast Has breast sparing surgery. LNs are negative Tumor is positive for ER and PR and negative for HER 55 year old woman with a reddened mass of the left breast, adherent to the chest wall and edematous left upper extremity No distant metastases; ER-PR-

Clinical case 79 year old man with colon cancer metastatic to the liver . Previously controlled with chemotherapy but now disease is progressing MSI negative Wants to live 6 more months to the wedding of his granddaughter

Evaluation of response to treatment Metastatic disease Adjuvant Treatment Neoadjuvant treatment

Evaluation of response: Metastatic disease Measurable disease non-measurable disease Change in size (RECIST) Vitality New lesions Time to progression Survival CTC Liquid Biopsy Disappearance Vitality New lesions Time to progression Survival CTC Liquid biopsy

Evaluation of response: adjuvant and neoadjuvant Change in size Vitality Disease free survival Survival Disease free survival Survival

Conclusions Treatment related decisions include assessment of patient’s condition and goals, stage of diseases, sensitivity to treatment and treatment toxicity Assessment of response in the presence of measurable disease involves: size, tumor vitality, time to progression and survival Assessment of response in the adjuvant setting includes disease free survival and overall survival