Oncology (I)

I really disliked the ‘Pocket…’ part of this book, so I’ll sort of pretend to overlook this aspect also in my coverage of the book here. This’ll be a hard thing to do, given the way the book is written – I refer to my goodreads review for details, I’ll include only one illustrative quote from that review here:

“In terms of content, the book probably compares favourably with many significantly longer oncology texts (mainly, but certainly not only, because of the publication date). In terms of readability it compares unfavourably to an Egyptian translation of Alan Sokal’s 1996 article in Social Text, if it were translated by a 12-year old dyslexic girl.”

I don’t yet know in how much detail I’ll blog the book; this may end up being the only post about the book, or I may decide to post a longer sequence of posts. The book is hard to blog, which is an argument against covering it in detail – and also the reason why I haven’t already blogged it – but some of the content included in the book is really, really nice stuff to know, which is a strong argument in favour of covering at least some of the material here. The book has a lot of stuff, so regardless of the level of detail of my future coverage a lot of interesting stuff will of necessity have been left out.

My coverage below includes some observations and links related to the first 100 pages of the book.

…

“Understanding Radiation Response: The 4 Rs of Radiobiology
Repair of sublethal damage
Reassortment of cells w/in the cell cycle
Repopulation of cells during the course of radiotherapy
Reoxygenation of hypoxic cells […]

*Oxygen enhances DNA damage induced by free radicals, thereby facilitating the indirect action of IR [ionizing radiation, US] *Biologically equivalent dose can vary by a factor of 2–3 depending upon the presence or absence of oxygen (referred to as the oxygen enhancement ratio) *Poorly oxygenated postoperative beds frequently require higher doses of RT than preoperative RT [radiation therapy] […] Chemotherapy is frequently used sequentially or concurrently w/radiotherapy to maximize therapeutic benefit. This has improved pt outcomes although also a/w ↑ overall tox. […] [Many chemotherapeutic agents] show significant synergy with RT […] Mechanisms for synergy vary widely: Include cell cycle effects, hypoxic cell sensitization, & modulation of the DNA damage response”.

“Specific dose–volume relationships have been linked to the risk of late organ tox. […] *Dose, volume, underlying genetics, and age of the pt at the time of RT are critical determinants of the risk for 2° malignancy *The likelihood of 2° CA is correlated w/dose, but there is no threshold dose below which there is no additional risk of 2° malignancy *Latent period for radiation-induced solid tumors is generally between 10 and 60 y […]. Latent period for leukemias […] is shorter — peak between 5 & 7 y.”

“The immune system plays an important role in CA surveillance; Rx’s that modulate & amplify the immune system are referred to as immunotherapies […] tumors escape the immune system via loss of molecules on tumor cells important for immune activation […]; tumors can secrete immunosuppressing cytokines (IL-10 & TGF-β) & downregulate IFN-γ; in addition, tumors often express nonmutated self-Ag, w/c the immune system will, by definition, not react against; tumors can express molecules that inhibit T-cell function […] Ubiquitous CD47 (Don’t eat me signal) with ↑ expression on tumor cells mediates escape from phagocytosis. *Tumor microenvironment — immune cells are found in tumors, the exact composition of these cells has been a/w [associated with, US] pt outcomes; eg, high concentration of tumor-infiltrating lymphocytes (CD8+ cells) are a/w better outcomes & ↑ response to chemotherapy, Tregs & myeloid-derived suppressor cells are a/w worse outcomes, the exact role of Th17 in tumors is still being elucidated; the milieu of cytokines & chemokines also plays a role in outcome; some cytokines (VEGF, IL-1, IL-8) lead to endothelial cell proliferation, migration, & activation […] Expression of PD-L1 in tumor microenvironment can be indicator of improved likelihood of response to immune checkpoint blockade. […] Tumor mutational load correlates w/increased response to immunotherapy (NEJM; 2014;371:2189.).”

“Over 200 hereditary CA susceptibility syndromes, most are rare […]. Inherited CAs arise from highly penetrant germline mts [mutations, US]; “familial” CAss may be caused by interaction of low-penetrance genes, gene–environment interactions, or both. […] Genetic testing should be done based on individual’s probability of being a mt carrier & after careful discussion & informed consent”.

“Pharmacogenetics: Effect of heritable genes on response to drugs. Study of single genes & interindividual differences in drug metabolizing enzymes. Pharmacogenomics: Effect of inherited & acquired genetic variation on drug response. Study of the functions & interactions of all genes in the genome & how the overall variability of drug response may be used to predict the right tx in individual pts & to design new drugs. Polymorphisms: Common variations in a DNA sequence that may lead to ↓ or ↑ activity of the encoded gene (SNP, micro- & minisatellites). SNPs: Single nucleotide polymorphisms that may cause an amino acid exchange in the encoded protein, account for >90% of genetic variation in the human genome.”

“Tumor lysis syndrome [TLS] is an oncologic emergency caused by electrolyte abnormalities a/w spontaneous and/or tx-induced cell death that can be potentially fatal. […] 4 key electrolyte abnormalities 2° to excessive tumor/cell lysis: *Hyperkalemia *Hyperphosphatemia *Hypocalcemia *Hyperuricemia (2° to catabolism of nucleic acids) […] Common Malignancies Associated with a High Risk of Developing TLS in Adult Patients [include] *Acute leukemias [and] *High-grade lymphomas such as Burkitt lymphoma & DLBCL […] [Disease] characteristics a/w TLS risk: Rapidly progressive, chemosensitive, myelo- or lymphoproliferative [disease] […] [Patient] characteristics a/w TLS risk: *Baseline impaired renal function, oliguria, exposure to nephrotoxins, hyperuricemia *Volume depletion/inadequate hydration, acidic urine”.

“Hypercalcemia [affects] ~10–30% of all pts w/malignancy […] Symptoms: Polyuria/polydipsia, intravascular volume depletion, AKI, lethargy, AMS [Altered Mental Status, US], rarely coma/seizures; N/V [nausea/vomiting, US] […] Osteolytic Bone Lesions [are seen in] ~20% of all hyperCa of malignancy […] [Treat] underlying malignancy, only way to effectively treat, all other tx are temporizing”.

“National Consensus Project definition: Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs to facilitate patient autonomy, access to information, and choice.” […] *Several RCTs have supported the integration of palliative care w/oncologic care, but specific interventions & models of care have varied. Expert panels at NCCN & ASCO recently reviewed the data to release evidence-based guidelines. *NCCN guidelines (2016): “Palliative care should be initiated by the primary oncology team and then augmented by collaboration with an interdisciplinary team of palliative care experts… All cancer patients should be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically indicated.” *ASCO guideline update (2016): “Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active tx. Referral of patients to interdisciplinary palliative care teams is optimal […] Essential Components of Palliative Care (ASCO) *Rapport & relationship building w/pts & family caregivers *Symptom, distress, & functional status mgmt (eg, pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation) *Exploration of understanding & education about illness & prognosis *Clarification of tx goals *Assessment & support of coping needs (eg, provision of dignity therapy) *Assistance w/medical decision making *Coordination w/other care providers *Provision of referrals to other care providers as indicated […] Useful Communication Tips *Use open-ended questions to elicit pt concerns *Clarify how much information the pt would like to know […] Focus on what can be done (not just what can’t be done) […] Remove the phrase “do everything” from your medical vocabulary […] Redefine hope by supporting realistic & achievable goals […] make empathy explicit”.

…

Some links:

Radiation therapy.
Brachytherapy.
External beam radiotherapy.
Image-guided radiation therapy.
Stereotactic Radiosurgery.
Total body irradiation.
Cancer stem cell.
Cell cycle.
Carcinogenesis. Oncogene. Tumor suppressor gene. Principles of Cancer Therapy: Oncogene and Non-oncogene Addiction.
Cowden syndrome. Peutz–Jeghers syndrome. Familial Atypical Multiple Mole Melanoma Syndrome. Li–Fraumeni syndrome. Lynch syndrome. Turcot syndrome. Muir–Torre syndrome. Von Hippel–Lindau disease. Gorlin syndrome. Werner syndrome. Birt–Hogg–Dubé syndrome. Neurofibromatosis type I. -ll- type 2.
Knudson hypothesis.
DNA sequencing.
Cytogenetics.
Fluorescence in situ hybridization.
CAR T Cell therapy.
Antimetabolite. Alkylating antineoplastic agent. Antimicrotubule agents/mitotic inhibitors. Chemotherapeutic agents. Topoisomerase inhibitor. Monoclonal antibodies. Bisphosphonates. Proteasome inhibitors. [The book covers all of these agents, and others I for one reason or another decided not to include, in great detail, listing many different types of agents and including notes on dosing, pharmacokinetics & pharmacodynamics, associated adverse events and drug interactions etc. These parts of the book were very interesting, but they are impossible to blog – US).
Syndrome of inappropriate antidiuretic hormone secretion.
Acute lactic acidosis (“Often seen w/liver mets or rapidly dividing heme malignancies […] High mortality despite aggressive tx [treatment]”).
Superior vena cava syndrome.