Oncology 101

Cancer Basics
 What Will You Learn?

 What is Cancer and How Does It Develop?

 Cancer Diagnosis and Staging
 Cancer Treatment
 What is Cancer?

Cancer is a group of more than 100 different

diseases characterized by the uncontrolled,
abnormal growth of cells.
We are made up of cells, which contain genes
 First Things First: Normal Cell Division

 Cells grow and divide (copy themselves) to form new cells

 When cells grow old or become damaged, they die and new cells take their
place
It all starts in the genes

Adapted from NCI

Under a microscope,
cancerous tissue
looks very different from
normal
(healthy) tissue
 What is Cancer? Summary Points

 Cancer is uncontrolled, abnormal growth of cells.

 Cancer results from changes or mutations in the genetic material
(DNA).
 Because it takes years for mutations to accumulate, cancer is
primarily a disease of aging.
 Tumors form when abnormal cells growing out of control form a
mass.
 Two Main Groups of Cancer

Blood cancers
Solid tumors (e.g., breast,
(e.g., leukemia, lymphoma)
prostate, colon, lung
cancers)
 What is a Tumor?

 A tumor is an abnormal
growth of cells that forms a
mass.
 Cancers can begin almost
anywhere in the body.
Benign Versus Malignant Tumors
 Major Classes of Cancer

 Carcinomas begin in the skin or in tissues covering glands or major organs (80-90% of all
cancers; e.g., breast cancer, colon cancer). Major subtypes are adenocarcinoma and
squamous cell carcinoma.

 Sarcomas begin in the connective tissue such as muscle or bone (Ewing sarcoma). Soft-tissue
sarcomas can begin in fatty tissue.

 Lymphomas begin in the lymphatic system, a network of glands and vessels that carries lymph
and white blood cells (e.g., Hodgkin lymphoma)

 Leukemias are cancers of blood-forming tissues including the bone marrow and the spleen
(e.g., acute lymphocytic leukemia)
 90% of cancer deaths
are due to metastases

Liver with pancreatic cancer metastases

If the cancer spreads, or metastasizes, from the place where it started to another part
of the body, the metastatic cancer is named for the part of the body where it started.

So, if a melanoma spreads to the liver, it’s called metastatic melanoma, not liver
cancer.
How Common is Cancer?

 4 out of 10 Americans will be diagnosed with cancer during their lifetime

 1.6 million: The estimated number of new cancer diagnoses in 2016.
 Due to the aging and growing population, by 2030, this number will rise to 2.3 million
per year.
How Common is Cancer?

 14.1 million: people diagnosed with cancer in 2012

 22 million: estimated number of new cancer diagnoses in 2030

Global Cancer Facts & Figures, 2015

Cancer is a Leading Cause of Death

 590,000: The number of Americans expected to die of cancer in 2016, about 1,600
people per day.
 8.2 million: World cancer deaths in 2012 (70% of the world’s cancer deaths occur in
developing countries )
 ↑80%: the estimated increase of world cancer deaths by 2030
 Do You Know?

What are the most common types of cancer in the United States?

Worldwide?
 Most Common Types of Cancer:
2016 Estimated New US Cancer Cases*
Men Women
Prostate 21% 841,390 843,820 29% Breast
Lung & bronchus 14% 13% Lung & bronchus
Colon & rectum 8% 8% Colon & rectum
Urinary bladder 7% 7% Uterus
Melanoma of skin 6% 6% Thyroid
Kidney & renal pelvis 5% 4% Non-Hodgkin
lymphoma
Non-Hodgkin 5%
lymphoma 4% Melanoma of skin
Oral cavity 4% 3% Kidney
Leukemia 4% 3% Pancreas
Liver & bile duct 3% 3% Leukemia
All Other Sites 19% 21% All Other Sites
*Excludes basal and squamous cell skin cancers
and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2016.
 Most Deadly Forms of Cancer:
2015 Estimated US Cancer Deaths

Lung & bronchus 27% Men Women 26% Lung & bronchus
Prostate 8% 314,290 281,400 14% Breast
Colon & rectum 8% 8% Colon & rectum
Pancreas 7% 7% Pancreas
Liver & intrahepatic 6% 5% Ovary
bile duct
4% Leukemia
Leukemia 4%
3% Uterine
Esophagus 4%
3% Non-Hodgkin
Bladder 4% lymphoma
Non-Hodgkin 4% 3% Liver & intrahepatic
lymphoma bile duct
Kidney 3% 2% Brain/nervous system
All other sites 24% 23% All other sites
Source: American Cancer Society, 2016
Most Common Cancers

Lung
Breast
Prostate
Colorectal Colorectal
Stomach Lung
Liver Cervical
Urinary Bladder Stomach
Uterine
What Causes Cancer?
 Not Those Mutations Again!
 Recall…cancer is caused by changes—mutations—in genes
that control the growth
and death of cells.

• Accumulating many
of these bad
mutations can lead
to cancer. No
single event turns a
normal cell into a
cancer cell.
 Risk Factors for Cancer

 Certain environmental and lifestyle factors can cause genetic

changes (mutations) that lead to growth of cancer.

 These influences are called risk factors: A risk factor is anything that
increases your chances of getting a disease.
 Age is the biggest cancer risk factor
Cancer Risk and Aging

400 Colon

Number of Breast
Cancer Cases 300
(per 100,000
people)
200

100

0 20 40 60 80
Age of Person (in years)
AACR Cancer Progress
Report 2014
Tobacco causes 18 types of cancer!

171,000: The estimated

number of U.S. cancer
deaths in 2015 that were
due to smoking.

AACR Cancer Progress Report 2013

 Healthy Weight and Lifestyle

• 1 in 3: Cancer deaths due to being

overweight, poor diet and/or lack of physical
activity

Want to know more about the link between obesity and cancer?

Cancer.net video: http://www.cancer.net/navigating-cancer-care/videos/after-

treatment-and-survivorship/link-between-obesity-and-cancer
 How Can You Reduce Your Risk?

AACR Cancer Progress Report 2014

 Hereditary Cancers

Sporadic Cancers Hereditary or Familial Cancers

Most cancers (90%-95%) A small proportion (5%-10%)

result from a series of of cancers-- result from
mutations passed from
acquired genetic a parent (or both parents)
mutations caused by to a child.
tobacco, sunlight,
radiation, et cetera.
 Hereditary Cancers

 So, sometimes, you are born with a gene mutation and can pass the mutation to
offspring
 This means that you are more likely to accumulate the number of mutations (“hits”)
needed for development of cancer
 However, even having an inherited gene mutation does not always mean you will
develop cancer. But your risk is increased. The rest of the mutations are left up to
chance (and exposure)
Hereditary cancer predispositions
 BRCA1, BRCA2 gene mutations (breast, ovarian, prostate,
pancreatic and other cancers)* Check out : Understanding
Hereditary Breast and Ovarian Cancer Oncology 101
Session
 APC gene mutations (colorectal cancers)
 TP53 gene mutations (breast cancer, sarcoma, leukemia,
brain tumors, and other)
 PTEN gene mutations (breast, thyroid, endometrial, other)
 Lynch syndrome (GI and GYN cancers, brain, breast
cancer)
 RB1 gene mutation (retinoblastoma, eye cancer)
 Von Hippel-Lindau syndrome (kidney cancer)
 Summary: How Does Someone Get Cancer?

 Cancer results from uncontrolled cell growth

 Changes in genes can result in production of abnormal proteins or
abnormal amounts of proteins – such proteins “tell” the cell to keep
growing and dividing
 Certain environmental and lifestyle factors can cause mutations that
allow the growth of cancer
 Multiple mutations are needed (some can be inherited)
Cancer Screening, Diagnosis and Staging Basics

How Do I Find Out If I Have Cancer?

 Signs and symptoms

 Screening tests
 Diagnosis tests
 Incidental (chance) findings
Common Signs and Symptoms

 Nagging cough or hoarseness

 Unplanned weight loss
 Changes in bowel or bladder habits
 New thickening or lump in any part of the body
 Unusual bleeding or discharge
 New mole or obvious change in the appearance of an existing mole or wart
 Common Cancer Screening Tests

 Colonoscopy (colorectal cancer)

 Mammography (breast cancer)
 PAP & HPV Tests (cervical cancer)
 PSA (prostate specific antigen; prostate
cancer)
 Note that such tests are not widely available
in low-resource settings/countries
Uses of Colonoscopy
Mammography
 Biopsy, or “Tissue is the Issue”
Biopsy - a very small piece of tissue from the abnormal area
(solid tumor) is removed and examined under a microscope by a
pathologist. In addition, molecular tests can be performed on the
tissue.
Biopsy tissue specimens under a microscope (pathology review)
 Summary: Cancer Diagnosis
 There may be signs or symptoms that result in a doctor’s visit
 Various types of screening tests can identify possibility of cancer (e.g., suspicious mass
on a scan, abnormal blood test)
 Biopsy is the main way to confirm diagnosis of cancer.
 Cancer Staging

 Cancer staging is a way of describing the severity of a cancer, such

as:
 How large is the tumor?
 Where is it located?
 Has it spread?
 The TNM Cancer Staging System
Doctors look at these three factors to determine the stage of
cancer:
How large is the Has the tumor Has the cancer spread
primary tumor and spread to the lymph to other parts of the
where is it located? nodes? (Node, N) body? (Metastasis, M)
(Tumor, T)
 Cancer Stage Groupings I - IV

 Stages are written as Roman numerals one through four (I, II, III, IV).
 Staging helps doctors establish a prognosis and prescribe
appropriate therapy.
 A cancer with a lower stage is usually associated with a better
prognosis.
• Tumor Grade: describes how much the tumor tissue
looks like healthy tissue when viewed under a
microscope.

Higher tumor grade usually

means more aggressive cancer
and worse prognosis.

Gleason scale (score) designates grade of prostate tumor

What Are the Different Cancer Treatments?
 Broad Categories of Treatment I

 Local therapy is intended to treat a tumor at the site without affecting

the rest of the body. E.g., surgery and radiation therapy.

 Systemic therapy refers to drugs which can be given by mouth or

directly into the bloodstream (i.v.) to reach cancer cells anywhere in
the body (e.g., chemotherapy, hormone therapy, and targeted
therapy.)
 Broad Categories of Treatment II
 Sometimes adjuvant (additional) therapy is given after surgery or
other main cancer treatment to kill cancer cells that may have
broken away from the primary tumor and begun to spread through
the body by way of the bloodstream.

 Neoadjuvant therapy, usually chemotherapy, may be given to shrink

a tumor before surgery.
 Types of Cancer Treatments

 Surgery
 Radiation Therapy
 Chemotherapy
 Hormonal Therapy
 Targeted Therapies
 Immunotherapy
 Palliative Care
 Supportive Care
 Cancer Surgery

 Surgery offers the greatest chance

for cure for many types of cancer,
especially those that have not
spread to other parts of the body.
Most people with cancer will have
some type of surgery.

 Cancer surgery is done by surgical

oncologists or general surgeons,
7% of ASCO membership.
 Radiation Therapy

 Radiation therapy uses radiation (high-energy x-rays, gamma

rays, neutrons, protons) to destroy cancer cells.
 Radiation may come from a machine outside the body
(external-beam radiation therapy), or it may come from
radioactive material placed in the body near cancer cells
(internal radiation therapy). Radiation therapy is usually a local
therapy.
 Systemic radiotherapy uses a radioactive substance, such as
a radiolabeled monoclonal antibody, that travels in the blood to
tissues throughout the body.
Use of Radiation

 Radiation can be used either as

a primary therapy (prostate
cancer) or as an adjuvant
therapy (breast cancer)

External-beam radiotherapy
 Radiation Therapy

 Side effects of radiation therapy include fatigue, swelling, and skin

changes.

 Radiation therapy is given by radiation oncologists, 8% of the ASCO

membership.
 Chemotherapy
Chemotherapy is the use of
drugs to destroy cancer
cells.

Chemotherapy is a systemic
therapy, or a therapy that
targets cells throughout the
body.
 Chemotherapy

 Chemotherapy works by stopping or slowing the growth of cancer cells,

which are rapidly growing and dividing.

 Side Effects: Because a lot of normal cells in the body also grow and
divide rapidly, for instance, cells that line the gut and that cause the hair
to grow, a lot of normal cells are also harmed by chemotherapy. This
translates into side effects like nausea and vomiting, and hair loss.
 How Is Chemotherapy Used?

 Chemotherapy is the main treatment for many blood cancers.

 Chemotherapy is commonly used to:
 destroy any cancer cells that remain after surgery or radiation therapy and
reduce chance of recurrence. This is adjuvant chemotherapy.
 Also used to shrink tumors before surgery or radiation therapy (neoadjuvant
chemotherapy).
 Also used to treat recurrent cancer (cancer that has come back in a person
thought to be cancer-free) or metastatic cancer (cancer that has spread
from the original location).
 Chemotherapy

 Chemotherapy generally does not require a hospital stay (inpatient setting); it is usually
given in an outpatient setting, including the medical oncologist’s office. Patients can
take oral chemotherapy at home.
 Chemotherapy is given by medical oncologists or hematologists, 77% of the ASCO
membership.
 Hormonal Therapy

Some cancers (e.g., breast , prostate cancers) depend on

hormones to grow.

Hormonal therapy blocks these hormones to limit growth of these

cancers.

Hormonal therapy is a systemic therapy.

 Hormonal Therapy

Hormonal therapy is used to:

 destroy any cancer cells that remain after surgery or radiation therapy to
prevent recurrence. This is adjuvant hormonal therapy.
 treat recurrent cancer (cancer that has come back in a person thought to be
cancer-free) or metastatic cancer (cancer that has spread from the original
location).
 lower the risk of breast cancer in women at high risk for the disease.
Hormonal Therapy for Breast Cancer

Tamoxifen works by blocking estrogen from

attaching to breast cancer cells and fueling
their growth.
 Hormonal Therapy for Prostate Cancer

Common hormonal
therapies include anti-
androgens that reduce the
body's production of
testosterone,which fuels
prostate cancer growth.
Side Effects of Hormonal Therapy
 Tamoxifen
 hot flashes
 increased risk of uterine cancers
 increased risk of blood clots
 Anti-androgens
 hot flashes
 impaired sexual function
 loss of sex drive
 weakened bones
 Precision or Personalized Medicine

 Targeted treatments are matched to genetic changes in the tumor.

 Such changes result in abnormal molecules (usually proteins) that cause cells to grow
out of control.
 Such abnormal molecules are the “targets,” that can be blocked by targeted therapy.
Different Targets in Lung Cancers
What do targeted cancer therapies do?

Targeted
cancer drugs
have been in
use for less
than 20 years.

American Lung Association

“Targets” can be near the cancer cell, on its surface or inside
 Targeted Cancer Therapies

 Targeted therapies are given by medical oncologists and often in

combination with other cancer therapies.

 Generally, these therapies do not have the same side effects as

traditional chemotherapy. Side effects are varied and depend on the
particular drug.

 See Oncology 101 Molecular Pathways slides for more info

 Targeted Cancer Therapies: An Example

 About one in five patients with breast cancer have too

much of a protein called human epidermal growth factor
receptor 2 (HER2) on the surface of tumor cells.
HER2 Targeted Cancer Therapies

Four different drugs

that block HER2 are
currently approved by
the FDA for use in
breast cancer
treatment.
 Targeted Therapy – Keep in Mind

 Targeted cancer therapies only work if the person’s tumor has the
molecular target.
 Not all tumors have a target with an available drug.
 Not all patients with tumors that have a target are successfully
treated with the targeted drug that matches that abnormality.
 All patients eventually develop resistance to targeted therapy.
 What is Cancer Immunotherapy?

 Immunotherapy harnesses the power of the immune system to fight against

cancer.
 Drugs help the immune system find and destroy cancer cells.
 In 2016, the FDA approved immunotherapy treatments for kidney cancer,
bladder cancer, head and neck cancer and Hodgkin lymphoma (previous
approvals for melanoma and lung cancers)
 See Oncology 101 Molecular Pathways and Understanding Immunotherapy
Sessions slides for more info on how immunotherapy works
 Also view ASCO’s Clinical Cancer Advances report.
Conclusion and Summary

• Cancer – genes and environment

• A small % hereditary
• How cancers are named
• Screening, Diagnosis, Staging
• Types of treatment