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31 Cards in this Set

  • Front
  • Back
Gold Standard in Evaluating the benefit of a cancer screening tool
Randomized clinical trial
Specificity and Sensitivity
+ and - predictive value
Predictive value is dependent on incidence of the disease (or in a trial by their sample size)
Efficacy= qualitative (does the intervention (drug/procedure) work?)

Effectiveness= quantitative (how well an intervention works in a population as a whole)
Lead time bias
It is possible through screening that a patient may have earlier detection and still die at the same time as someone diagnosed later
goal of cancer screening tests
to decrease the death rate and mortality

Should not be based on length of survival- subject to too much bias!
Length bias
Based on the biological behavior of a tumor and screening intervals

If a tumor is found IN BETWEEN screening, it is more likely to be more aggressive and symptomatic than one picked up on a screen
Over Diagnosis as bias
a type of length bias

ex. Prostate cancer or Neuroblastomas in kids <5

*may never become problematic and result in invasive tests and treatment
False +/- screening
Specificty= the number of negative patients that had negative test results (shows false positives)

Sensitivity= the number of positive patients that had positive test results (shows false negatives)
Breast Cancer Risk Factors
Individual Risk Factors
1. Female Gender
2. Prior breast cancer or proliferative lesion as seen on histology
3. Genetic inheritance
4. Age (starting at age 50)
5. Radiation (most in-utero, then childhood/during breast development)
6. Alcohol– 2 drinks a day increases your risk by 20%, etc

Population Risk Factors
1. Age at first childbirth- greatest risk if no kids because their breast tissue never has to fully mature
2. Age of menarche
3. Age of menopause
4. Nursing a child
Premalignant Breast Changes
1. Ductal hyperplasia – doesn’t increase risk
2. Atypical ductal hyperplasia – cells aren’t normal but aren’t quite malignant- a step towards malignancy.
3. Ductal carcinoma in situ – a unilateral premalignant lesion- have not demonstrated ability to penetrate basement membrane or metastasize
4. Atypical lobular hyperplasia – same risk as atypical ductal hyperplasia.
5. Lobular carcinoma in situ –is NOT an in situ carcinoma, it is simply a description of lobular neoplastic-looking cells-a bilateral problem

* All of these risk factors can be greatly reduced by taking Tamoxifen
Types of Breast Cancer
1. Infiltrating ductal carcinoma: >85%
2. Invasive lobular carcinoma: 8-10%- acts like infiltrating but harder to diagnosed (esp with mamogram)
3. Colloid carcinoma – 2-3% with a favorable prognosis
4. Tubular carcinoma –2% if pure tubular is benign
Spread of Breast Cancer
Regional: axillary lymph nodes, internal mammary lymph nodes, supraclavicular lymph nodes

Blood stream: attains the ability to spread/metastasize through the blood after it has spread to the lymph nodes

Distant metastases: bone, liver, lung, brain, skin, peritoneum
Heritable Breast Cancer

Get a 3 generational family tree

1. Cancer in 2 or more close relatives (or on the same side of the family)esp if very young
2. Early age of diagnosis (i.e. 30 years old)- need MRI not mamogram
3. Multiple primary tumors (breast and ovary)
4. Bilateral or multiple rare cancers
5. male breast cancer in the family (BRCA2 mutation)
6. BC and sarcoma (Li Fraumeni syndrome)
7. Constellation of tumors consistent with specific cancer syndrome (breast and ovary)
8. Evidence of autosomal dominant transmission
Progression of Breast Cancer
Ductal hyperplasia > Atypical ductal hyperplasia (ADH) > Ductal carcinoma in situ (DCIS) > DCIS with microinvasion with eventual basement membrane invasion > Invasive DCIS
Breast Cancer Prognostic Factors
tumor size
lymph node involvement * only reliable factor
tumor grade

*Low grade tumors tend to be ER (estrogen receptor) positive while Grade 3 tumors are ER negative
(really no such thing as grade 2)
Clinical Presentation of Breast Cancer
Most women present with perfectly normal breasts

- crusty nipples.
- Paget’s disease of the nipple – eczematous appearance of epithelial involvement
- inverted nipple
- locally invasive disease
- Inflammatory BC-heat and erythema over more than 50% of the breast * most dangerous and most rapidly progressive
Breast Cancer Treatment
Mild to Intermediate disease can be treated with Tamoxifen alone (75% of patients) for 50% reduction

Severe disease can benefit from chemotherapy for 50% reduction (no response to Tamoxifen)

* with genomics we can tailor our therapy
Lung Cancer Definition
2nd most common cancer (behind skin) but the most deadly!

uncontrolled growth of malignant cells in one or both lungs and tracheobronchial tree- K-ras is mutated, akt is turned on, PTEN is lost
Lung Cancer risk factors
1. Amount smoked in pack-years
2. Age of onset (the younger you are, the better your capacity for DNA repair)
3. Product smoked (filtered, tar/nicotine)
4. Depth of inhalation
5. Gender (being female is protective)
Lung cancer screening
CT screening DOES NOT reduce mortality!

It might pick up lung cancer earlier and at earlier stages- but will it actually effect treatment?
Lung Cancer Clinical Presentation
Local symptoms (indicative local airway invasion):
cough, dyspnea, hemoptysis, recurrent infxns (eg, smokers who have serial pneumonias points to LC), chest pain

weight loss, fatigue

Syndromes/Symptoms secondary to regional metastases:
Esophageal compression= dysphagia
Laryngeal n. paralysis = hoarseness
Sympathetic n. paralysis= Horner’s
Cervical/thoracic n. invasion= Pancoast syndrome
Lymphatic obstruction= pleural effusion
Vascular obstruction= SVC syndrome
Pericardial/cardiac extension = effusion, tamponade

Lung cancer has the tendency to go to the LNs, brain (favorite), bones, liver, lung pleura, and adrenal glands
Non-Small Cell Lung Cancer- NSCLC

85% of all lung cancer
Better survival rates (if found early)
More peripherally (small cell=central)

1. Adenocarcinoma (most common)
2. Squamous cell carcinoma
3. Bronchoalveolar carcinoma
4. Large cell carcinoma
5. Adenosquamous
Lung cancer

diagnostic tests vs Staging
Chest X-ray and tissue biopsy

1. Bronchoscopy (central obstruction)
2. Mediastinoscopy
3. LN assessment
4. VATS (Video-Assisted Thorascopy)
5. PET scan
6. Bone scan if you suspect metastasis
Treatment of Lung Cancer
hylar nodes only- Surgery

mediastinal mass- chemo/radiation

Genomic based Therapy-
1. EGFR+ use targeted therapy- can develop resistance
2. VEGF inhibitors- block angiogenesis
Paraneoplastic Syndromes

must be directly due to a tumor but at a distant site

Doesn't always resolve with remission
Nervous System Paraneoplastic Syndromes
* always consider metastasis to the brain first- more common

Encephalomyelitis- cross-reactivity antibodies [SCLC]

Lambert-Eaton- cross-reactivity antibodies [SCLC]
Small Cell Lung Cancer Paraneoplastic Syndromes

SIADH * common
Endocrine Paraneoplastic Syndromes
Cushings= ACTH levels are high [SCLC, carcinoid, medullary thyroid]


Necrolytic Migratory Erythema [glucagonoma]

Acanthosis Nigricans [stomach/GI tract tumors]
Cutaneous Paraneoplastic Syndromes
usually related to cytokine release
Generalized Erythroderma- usually drug related [cutaneous T cell Lymphoma]

Acquired ichthyosis- sclaing [hodgkins, MM, polycythemia vera]

Amyloidosis- peri-orbital purpura, etc [MM]

Sweet Syndrome- acute febrile neutrophilic dermatosis [hemetologic- AML]
Pulmonary System Paraneoplastic Syndromes
Clubbing and hypertrophic pulmonary osteoarthropathy [adenocarcinoma or squamous cell carcinoma of the lung]
Oncologic Emergencies
1. Spinal Cord Compression [breast, lung, prostate, SCLC inside cord

2. Hypercalcemia- PTH like protien, lytic lesions, Vit D like protein [squamous cell lung cancer, MM, lymphoma]

3. Tumor Lysis Syndrome- Uric acud, K+, PO4, and Ca [fast growing tumors- Burkitts, etc] Tx w/Allopurinol

4. DIC [Adenocarcinoma and hemotologic tumors]

5. Hyperleukocytosis- blood sludges [ALL or AML]

6. Fever and Neuropenia- opputunistic infection (esp pseudomonas) [Chemo rxn]

7. Superior Vena Cava Syndrome- swelling of face and extremities [Iatrogenic/central line, SCLC or lymphoma]

8. Pericardial Effusion/Tamponade