Cancer ManagementCancer ManagementHow do we decide?How do we decide?

Alex J CrandonAlex J CrandonMB BS (Syd) PhD (Leeds) FRCOG (Lond) FRANZCOG (Melb) CGOMB BS (Syd) PhD (Leeds) FRCOG (Lond) FRANZCOG (Melb) CGO

Gynaecological OncologistGynaecological OncologistMater and Brisbane Private HospitalsMater and Brisbane Private HospitalsDirector Qld Centre for Gyn. CancerDirector Qld Centre for Gyn. Cancer

Principles of Cancer Principles of Cancer ManagementManagement

1.1. Make a diagnosisMake a diagnosis

2.2. Determine disease distributionDetermine disease distribution

3.3. Ask: “What is the aim of Ask: “What is the aim of treatment?” Cure or palliationtreatment?” Cure or palliation

4.4. What does the literature say is What does the literature say is the best way to achieve the the best way to achieve the identified aim of treatment.identified aim of treatment.

Current TreatmentsCurrent Treatments

These are in no specific order:These are in no specific order: Surgery,Surgery, Radiotherapy,Radiotherapy, Chemotherapy,Chemotherapy, Some combination of above, orSome combination of above, or Do nothing.Do nothing.

SurgerySurgery

This involves the This involves the treatment of a treatment of a specific region. specific region. Generally by Generally by removing the removing the offending tumour offending tumour +/- surrounding +/- surrounding tissue and draining tissue and draining lymph nodes.lymph nodes.

RadiotherapyRadiotherapy

Uses x-rays to Uses x-rays to treat cancer.treat cancer.

Some cells killed Some cells killed out-right.out-right.

Many more cells Many more cells damaged and damaged and die later trying die later trying to reproduceto reproduce

ChemotherapyChemotherapy

Uses chemicals Uses chemicals called cytotoxics called cytotoxics to damage cells to damage cells so they die out-so they die out-right or when they right or when they try to reproduce.try to reproduce.

Not all chemo Not all chemo makes you sick-makes you sick-there are over 80 there are over 80 different drugsdifferent drugs

Palliative CarePalliative Care

Doesn’t mean Doesn’t mean your about to your about to die.die.

Your treatment is Your treatment is no longer aimed no longer aimed at cure but at at cure but at quality of lifequality of life

You may be You may be undergoing undergoing palliative care for palliative care for years.years.

New TreatmentsNew Treatments

Identify the new treatmentIdentify the new treatment Test it for:Test it for:

Safety – how much to give or do?Safety – how much to give or do? What side-effects?What side-effects? Effectiveness?Effectiveness? Then compare with standard best Then compare with standard best

therapy, i.e., a prospective clinical therapy, i.e., a prospective clinical trialtrial

Phase 1 TrialsPhase 1 Trials

Phase 1 trials are done to find Phase 1 trials are done to find out out The safe dose range           The safe dose range           The side effects           The side effects           How the body copes with the drug How the body copes with the drug 

    People entering phase 1 trials People entering phase 1 trials often have advanced cancer often have advanced cancer and have usually had all the and have usually had all the treatments available to them.  treatments available to them. 

Phase 2 TrialsPhase 2 Trials

Phase 2 trials are done to find out Phase 2 trials are done to find out

If the new treatment works well If the new treatment works well enough to test in a larger phase 3 enough to test in a larger phase 3 trial           trial          

Which types of cancer the treatment Which types of cancer the treatment works for   works for  

More about side effects and how to More about side effects and how to manage them           manage them          

More about the best dose to use More about the best dose to use

Phase 3 TrialsPhase 3 Trials

These trials compare new treatments These trials compare new treatments with the best currently available with the best currently available treatment (the standard treatment). treatment (the standard treatment). They may compareThey may compare

A completely new treatment with the A completely new treatment with the standard treatment        standard treatment       

Different doses or ways of giving a Different doses or ways of giving a standard treatment        standard treatment       

A new radiotherapy schedule with the A new radiotherapy schedule with the standard onestandard one

Example of ProblemsExample of Problems

A new drug was developed for A new drug was developed for ovarian cancerovarian cancer

Phase 3 trial: Phase 3 trial: multimillion dollar international trial multimillion dollar international trial given after surgery compared with given after surgery compared with

the then standard therapy showed the then standard therapy showed it worked better than standard it worked better than standard therapytherapy

Example of Problems 2Example of Problems 2

New studies about the same time New studies about the same time showed that survival after showed that survival after ovarian cancer treatment was ovarian cancer treatment was much better for patients who had much better for patients who had been optimally debulked at been optimally debulked at surgerysurgery

Example of Problems 3Example of Problems 3

Questions were asked about the Questions were asked about the debulking success in the new debulking success in the new chemotherapy trialchemotherapy trial

When looked at it was found that When looked at it was found that by chance alone most of the by chance alone most of the optimally debulked patients had optimally debulked patients had ended up in the group that got the ended up in the group that got the new drugnew drug Are we seeing the effect of the new Are we seeing the effect of the new

drug or the optimal debulking?drug or the optimal debulking?

Example of Problems 4Example of Problems 4

Back to the drawing boardsBack to the drawing boards A new multimillion dollar A new multimillion dollar

international trial to allow for the international trial to allow for the effects of the debulkingeffects of the debulking

It turned out that in both It turned out that in both optimally and non-optimally optimally and non-optimally debulked groups the new debulked groups the new chemotherapy did betterchemotherapy did better

Complementary or Complementary or Alternative TreatmentAlternative Treatment

Most medicos have little problem Most medicos have little problem with complementary treatmentwith complementary treatment

They recognise that many of our They recognise that many of our current drugs started as plant or current drugs started as plant or animal extractsanimal extracts

We know what we are giving the We know what we are giving the naturopath does not.naturopath does not.

St Anthony’s FireSt Anthony’s Fire

Ergotism – a painful disease with Ergotism – a painful disease with seizures, spasms, diarrhoea, seizures, spasms, diarrhoea, vomiting, paresthesia, headaches, vomiting, paresthesia, headaches, burning in limbs sometimes burning in limbs sometimes leading to gangrene and deathleading to gangrene and death

Eating bread made from rye Eating bread made from rye infected with a fungus infected with a fungus claviceps claviceps purpureapurpurea

Ergot & MidwivesErgot & Midwives

Midwives knew that women having Midwives knew that women having post partum haemorrhage could be post partum haemorrhage could be stopped from bleeding by giving stopped from bleeding by giving them some ergot infected breadthem some ergot infected bread

Problem: sometimes they killed Problem: sometimes they killed women with ergotismwomen with ergotism

We have discovered that the active We have discovered that the active ingredient is ingredient is ergometrineergometrine and now and now we give that or its synthetic cousin we give that or its synthetic cousin syntocinon.syntocinon.

Legislative requirementsLegislative requirements

Only a licensed Vet can operate Only a licensed Vet can operate on an animalon an animal

Only a licensed gas fitter or Only a licensed gas fitter or plumber can install a gas stove plumber can install a gas stove or water heateror water heater

Only a qualified electrician can Only a qualified electrician can rewire your houserewire your house

Legislative EnigmaLegislative Enigma

Anyone can hang up a piece of Anyone can hang up a piece of wood saying “Naturopath”, wood saying “Naturopath”, “Herbalist”, “Iridologist” or “Rake “Herbalist”, “Iridologist” or “Rake Healer” etc and provide treatment Healer” etc and provide treatment in isolation to people with cancerin isolation to people with cancer

These people have never provided These people have never provided a single phase 3 study to backup a single phase 3 study to backup their treatment(s)their treatment(s)