1. Oncology for Family Medicine Residents Module 1: Workup of Suspected Malignancy Anna N Wilkinson, MD, MSc, CCFP

2. 1.Work up of suspected malignancies 2.Oncology Basics Chemotherapy and Radiation Therapy 3.Oncology Emergencies 4.Survivorship care Ongoing monitoring of patients and management of sfx treatment and longer term drugs Objectives

3.  Family Physicians are first line for workup of malignancy  Patients may present to primary care with signs or symptoms prompting diagnosis of already metastatic cancer  Patients continue to see their family physician during treatment  Patients present to ER with acute complications of malignancy or treatment  Some emergencies are reversible, or morbidity minimised if treated promptly  Patients value their relationship with their FP and often seek their advice to assist in decision making  More and more survivorship care the responsibility of FPs Why do I need to know about Oncology???

4.  High Index of Suspicion  Once a Cancer Patient Always a Cancer Patient

5. Lung Prostate Colon Breast Work up of Suspected Malignancies

6. Workup of Lung ca

7. Mr X is a 72 yo male with a 50 pack year smoking history. He presents to your office with a non- resolving cough and 15 lbs weight loss over the last 3 months. Given his smoking history, you order a chest xray. Case #1

8. Chest X Ray

9.  Physical Exam  Labs  CBC, electrolytes, Cr, Ca, Albumin, LDH, LFT’s, INR  CT chest (with contrast)  Referral to rapid assessment centre if possible Next Steps

10. CT Thorax

11.  Tissue Diagnosis  Referral Next Steps

12.  Any suspected malignancy requires tissue confirmation, pathology will dictate treatment options  Tissue may be obtained via Mediastinoscopy Endoscopy Endobronchoscopy Percutaneous FNA  Consider obtaining biopsy through Radiology, Respirology Thoracics, or Cancer Assessment Centre, depending on local resources Tissue Diagnosis

13.  Fine Needle Aspiration  Two essentials: Prior imaging (CT ) Blood work: INR and Platelets Lung Biopsy

14. FNA of lung lesion: “Abnormal cells with enlarged hyperchromatic nuclei and scant cytoplasm are present. Findings are consistent with a small cell carcinoma.” Pathology

15.  Blood Work CBC, electrolytes, LFT’s, Ca, Alb, LDH, Cr, INR  Pulmonary Function Testing (PFT’s)  Imaging Chest: CT Chest Abdomen: CT Abdomen Brain: CT or MRI Bone: Bone Scan or MRI axial skeleton PET/CT (oncology to order, if no evidence of metastatic disease on workup) Initial Evaluation of a Patient with Lung Cancer

16. Abdomen CT

17.  CT is easy to obtain and good screening technique  CT with contrast  MRI may be better if there is consideration of Leptomeningeal disease Cranial nerve involvement MRI vs CT brain

18. CT Brain

19. Mr. X is seen by medical oncology and found to have extensive small cell lung cancer. He is treated with cisplatinum/etoposide chemotherapy x 4 cycles, initially with good response. He also undergoes XRT for brain met. He declines after a further 3 months, and you provide palliative care for him at home until his death. Case Resolution

20. Workup of Prostate ca

21.  Mr. P, a 65 yo male, comes to you for his Periodic Health Exam. You detect a hard nodule on the superior aspect of his prostate. He endorses some mild urinary symptoms, including frequency and nocturia. He has no other systemic symptoms. Case #2

22.  Blood work  PSA, Cr, CBC, Ca, Alb, LFTs  PSA 21.4 ng/mL  Imaging/Biopsy What Should You Do Next?

23.  Do I need imaging prior to biopsy? No imaging is needed  Who does the biopsy? Ultrasound guided by Urology or Radiology Consider Cancer Assessment Centre if available Prostate Biopsy

24. Anticoagulation Management Avoid Aspirin, Advil, Ibuprofen for 5 days prior Coumadin- d/c 5 days prior and bridge with LMWH NOACs- stop 2-3 days prior and restart 2 days post Prophylactic Antibiotic Cipro 500mg bid at the day of the biopsy, duration 1-3d Preparation Fleet enema, available over the counter, 2 to 3 hours prior Light meal only prior to the appointment 2 hours total at the hospital Arrange for a ride home. Post biopsy 48 hours following biopsy, no heavy lifting or strenuous activity. Expect some blood with urine and stool for up to 3 days If febrile within 1 week post procedure seek medical attention Trans-rectal Prostate Biopsy

25. Core Biopsy: “Adenocarcinoma, Gleason 4+3 = 7” Biopsy Results

26.  Tumour Size  T1: Tumour not palpable and not visible with imaging  T2: Tumour confined within prostate  T3: Tumour extends through prostatic capsule  T4: Tumour is fixed or invades adjacent structures  Nodes  N0: no regional lymph node metastases  N1: Metastases in regional nodes  Metastases  M0: No metastases  M1: Distant metastases Staging of Prostate Cancer

27.  Life expectancy <5yrs and no clinical sx: no further workup  Life expectancy >5 yrs or symptomatic: staging appropriate Bone Scan if:  T1 + PSA > 20 or T2 + PSA >10  Gleason ≥ 8  T3 or T4  Symptomatic MRI Pelvis if:  T3 or T4 disease  T1 or T2 disease with high risk of nodal involvement Staging of Prostate Cancer

28. Pelvis MRI Bone Scan If equivocal consider MRI Urology/ Radiotherapy consult

29.  PSA  CT abdomen  MRI Pelvis  Bone Scan Staging Investigations

30.  CT Abdomen/Pelvis helpful for evaluation of lymph nodes  MRI pelvis for local staging to determine presence of extra-prostatic spread CT Pelvis vs MRI Pelvis

31. Palpable nodule: T2 Gleason: 7 PSA: 21.4 Therefore MRI, Bone Scan ordered Staging- Mr. P.

32. MRI

33. Wilkinson et al, Can Fam Physician. 2008 Feb; 54(2): 204–210.

34. Mr P is treated with a radical prostatectomy. 5 years later, his PSA remains undetectable. Case Resolution

35. Workup of Colon ca

36.  Mr. C has a positive FOBT test. You refer him for colonoscopy and a mass is biopsied and found to be an adenocarcinoma. What are your next steps? Case #3

37.  Colonoscopy due to positive FOBT or clinical concern  Once malignancy confirmed from colonoscopy bx  CBC, chemistry profile, CEA  Chest/abdominal/pelvic CT  Tumour (T) and Nodal (N)data from post operative pathology  Referral  Cancer assessment centre, surgical oncologist, medical oncology Work up of Colon Cancer

38.  You order the appropriate lab and imaging for Mr C and refer him to the Cancer Assessment Centre in your area. He goes on to have a hemicolectomy and remains disease free post procedure. Case Resolution

39. Workup of Breast ca

40.  Mrs. B presents to your clinic with a breast lump. On physical exam you confirm the 1 cm breast lump, and palpate no axillary nodes. What are your next steps? Case #4

41.  Early stage disease vs. locally advanced or inflammatory breast ca???  Early breast cancer:  Mass <5cm  Ipsilateral nodes may be present, but freely mobile  Locally advanced breast cancer:  Mass > 5 cm  Growing into the skin or chest wall  Present in ipsilateral axillary lymph nodes, nodes fixed or matted Breast Cancer Workup

42.  Clinically Stage 1-2: (tumours <5cm, or smaller with mobile axillary nodes)  Physical Exam  Diagnostic bilateral mammogram, ultrasound as necessary  Blood work: cbc, LFT, ALP  Bone Scan if symptoms  CT C/A/P if symptoms present only Diagnostic Workup for Breast Cancer- Early Stage Disease

43.  Biopsy if suggested by imaging results  Referral to Breast Surgeon or Cancer Assessment Centre if positive pathology Diagnostic Workup for Breast Cancer- Early Stage Disease

44. Locally Advanced or Inflammatory Breast Cancer Clinically Stage 3- (tumour >5cm, +axillary nodes) Locally Advanced Breast cancer Inflammatory Breast Cancer

45.  Biopsy  Rapid Referral  Staging Investigations  CBC, LFT, ALP  Chest CT  Abdominal/Pelvic CT  Bone Scan Diagnostic Workup for Breast Cancer- Locally Advanced or Inflammatory

46.  Mrs. B had reassuring imaging which showed a breast cyst only. You aspirated the cyst successfully, and continued with her regular screening mammograms. Case Resolution

47. Workup of Unknown Primary

48. Mrs Y, a 63 yo woman, comes to your office with symptoms of vague abdominal pain, low energy and unintentional weight loss of 10 lbs over the last two months. Case #2

49.  ROS otherwise negative  PMHx: 2 C-sections, hypertension  Meds: Altace 10mg od  Fam Hx: father prostate ca  Physical Exam: Normal with the exception of vague discomfort periumbilically  You order ultrasound abdomen/pelvis to further assess Physical

50.  Liver lesion 1.7 cm, suspicious for malignancy, small amount of ascites Ultrasound

51. Liver Lesion

53.  Complete hx/px Breast, pelvic, rectal, skin, adenopathy  Labs  Imaging CT Abdomen/Pelvis  Biopsy Liver Lesion What is next?

54.  Solitary hepatic lesion with features suggestive of metastasis CT Abdomen

55. Requirements pre-biopsy Prior CT or MRI INR and platelets Stop anticoagulation 6 hrs NPO prior to procedure Post-biopsy Arrange for a ride home No heavy lifting or strenuous activity for 48 hours following biopsy Deep Organ Biopsy

56. FNA of liver lesion: “Poorly differentiated adenocarcinoma, immunohistochemical results non diagnostic” Pathology Results

57. Symptom oriented workup Use pathology to guide investigations Lab Tumor Markers: BHCG, AFP, PSA, CA125, CA19-9, CEA urine cytology Imaging CT head CT Chest/Abdomen/Pelvis Mammogram Testicular ultrasound (in male with retroperitoneal mass) Bone scan Workup of Unknown Primary

58.  Procedures (if applicable)  Colonoscopy  Endoscopy  Cystoscopy  Thoracentesis  Paracentesis  Excisional biopsy if amenable lesion  Referral to Medical Oncology Workup of Unknown Primary

59. After extensive workup, Mrs. Y is diagnosed as cancer of unknown primary. She is treated with multiple lines of palliative chemotherapy. Case Resolution

60.  Wilkinson et al, Can Fam Physician. 2008 Feb; 54(2): 204–210  http://www.nccn.org/ References

61.  Cancer Care Ontario  https://www.cancercare.on.ca/https://www.cancercare.on.ca/  National Comprehensive Cancer Network  http://www.nccn.org/ http://www.nccn.org/  BC Cancer Agency  http://www.bccancer.bc.ca/ http://www.bccancer.bc.ca/ Resources