Cancer Treatment Process

If polyps are found during the colonoscopy, the specialist would have removed and sent it for microscopic examination - biopsy.

If the biopsy shows that the polyp

1. is cancerous- you may need surgery to remove the portion of the colon where the polyp was removed.
2. is precancerous - (all variety of adenomas) - you will need a periodic colonoscopy at a a regular interval depending on the number of other risk factors you may have -such as family history of colon cancer, number & size polyps you had & how "bad" the precancerous polyps were on biopsies.
3. Hyperplastic- usually of no concern. However, this subject has become a debate point lately & some scientists do believe that these polyps too may be a sign that you are at a risk of developing precancerous polyps later on.

There are other rare types too but that subject is beyond the discussion in this forum.

Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first!

Initiation of hormonal therapy is commonly begun after the completion of chemotherapy (and after completion of radiation therapy if you receive both). In terms of actual timing, hormonal therapy will typically begin approximately four to six weeks following completion of chemotherapy. A preference for sequential timing of chemotherapy and hormonal therapy, i.e., adjuvant chemotherapy followed by hormonal therapy, was suggested by a clinical trial, in which sequential versus concurrent chemo/hormonal therapy were directly compared and sequential treatment had superior outcomes for disease free and overall survival.

I would add that there are limited clinical data and no consensus on the use of concurrent hormonal therapy and radiation therapy, thus some medical oncologists advise overlap of hormonal therapy with radiation and others advise waiting until radiation is complete. I generally advise waiting until radiation is complete.

The stage of melanoma is determined from 3 factors - tumor thickness, lymph node status and distant spread. Tumor thickness is determined from the initial removal of the 'funny looking mole' and is literally a measurement of thickness under the microscope. Other factors of the primary melanomas are important - the main one being whether the melanoma is ulcerated or not. Ulcerated melanomas are 'upstaged' by 1/2 a tumor size stage compared to non-ulcerated melanomas. Other important factors (but not changing the tumor thickness stage) include mitotic rate (how fast the melanoma is dividing), regression, vertical growth phase and lymphovascular invasion. Lymph node status is determined by whether or not the melanoma has spread from the melanoma to the regional lymph nodes. This is usually determined by sentinel node biopsy. The number of affected lymph nodes is important along with the quantity of spread within the lymph node(s). If the sentinel lymph node is 'clean' (without melanoma), then the stage is determined by the thickness and ulceration status of the primary melanoma. If the melanoma has spread to the regional lymph nodes, the patient is classified as stage 3. Lastly is the determination of whether or not the patient's melanoma has spread through the body. This is usually done with CT or PET/CT scans and maybe a brain scan (CT or MRI). If the melanoma has spread elsewhere in the body (lung, liver, bone, brain, etc), then the patient automatically jumps to stage 4 regardless of the tumor thickness or lymph node status.

The margins of the wide excision are examined to make sure there is no melanoma at the edges. Rarely there is melanoma present along part of the margin (usually non-invasive melanoma in situ) and this will need to re-excised to 'negative' margins. The sentinel lymph node is the critical piece of information since it will determine if all surgical therapy is over (lymph node doesn't have any melanoma cells in it) or that more surgery (completion lymph node dissection) and possibly systemic therapy is needed.

Pathology reports usually take 2-5 days to return depending on the complexity of the case with most cases being done in 2-3 days. The sentienl node is thoroughly examined by both routine stains (hematoxylin and eosin) and special melanoma specific stains (HMB45).

Your surgeon needs your records including biopsy pathology report(s) and any other operative report you may have had. If you have had any scans, the reports and preferably a CD-ROM containing the actual scan images would be important. Often these records are forwarded to the surgeon fromt eh dermatologist or primary care physician but it is always very helpful if you check to make sure the surgeon has all pertinent records.

In my experience, patients come into my office fearing that they are going to die of their melanoma when the reality is that the vast majority of melanoma patients are cured of their melanoma - so most patients are reassured and relieved. The surgeon will give them a detailed discussion about melanoma and how it could potentially spread - locally, regionally and systemically and a plan to deal with each of these. Local spread requires a Wide Excision around the melanoma - generally 1cm radially out from the biopsy for each millimeter of thickness up to ~3cm from the biopsy site. Regional spread requires a sentinel lymph node biopsy to determine if the melanoma has spread to that lymph node. Systemic spread is assessed with body scans such as PET/CT, regular CT's, and MRI's.

Most patients with an invasive melanoma (of any Breslow thickness) should see a surgical oncologist. The main reason being to decide if there are features of the primary melanoma that would indicate a need to assess the sentinel (first draining) lymph node. Essentially all patients with a melanoma of 1.0 mm thickness and above should get a sentinel lymph node biopsy. Below 1.0 mm, there are certain features that would warrant getting a sentinel lymph node including ulceration, mitoses (cell divisions) >1, lymphovascular invasion, thickness >0.75mm, Clark's level 4 (Clark was a pathologist who measured melanomas based on the level it penetrated through the layers of the skin) and sometimes for patient reassurance. This last point is very loose but sometimes the psychological well being of having a 'clean' sentinel node biopsy is worth the very low chance of morbidity (pain, infection, extremity swelling).

The first visit post-diagnosis will be a discussion of the biopsy results, type of cancer, and treatment options. Additional tests will be mentioned. This will take in the order of 45 minutes to an hour. There should be ample time for questions. Families are encouraged to take notes. Literature may be provided to the patient and family. There may be referrals to other team members such as radiation oncology, medical oncology, plastic surgery, social work or counseling.

The NCCN publishes guidelines for followup.
http://www.nccn.com/files/cancer-guidelines/breast/index.html#/86/
Physical exam is indicated every 4-6 months initially. Annual blood work and tumor markers are often drawn. There is a trend away from routine imaging in asymptomatic patients.

Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves.

Most often a woman will see a breast surgeon early in the process - either before diagnosis as many breast surgeons perform their own minimally invasive biopsies, or shortly after diagnosis. The breast surgeon will usually consult with the medical oncologist, radiation oncologist and plastic surgeon and the specialists will all work as a team to determine the breast treatment approach for a patient.

This may be a woman's individual choice - if a woman is a candidate for immediate reconstruction, she may have a preference regarding the timing of the surgery. Some prefer to undergo the mastectomy and other treatment first, delaying the reconstruction, while some women like the idea of having a large part of the reconstruction performed at the time of the mastectomy. Some patients with more aggressive tumors are not candidates for immediate reconstruction, but if the woman has a choice, it is really an individual decision.

As soon as possible. Check in with an integrative oncologist so that you understand the potential interactions between any of your complementary therapies and conventional treatment. Also you should get some information on things you can be doing to help with side effects and get on to living a healthier life. Why wouldn’t you want to do that as soon as possible?

The 'cure' rate of Stage 1a melanoma is excellent and approaches 100% (there are few if any absolute 0%'s or 100%'s in medicine). The highest risk of recurrence of any melanoma is within the first 2 years so I see all my invasive melanoma patients every 3 months for the first 2 years and then every 6 months for 3 years and then yearly. However, there is also risk of developing a second melanoma unrelated to the initial melanoma at a rate of 0.5-1.0% per year for the rest of their life. Therefore, follow up should be every 3-6 months with their dermatologist in addition to the visits with their surgical oncologist.

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

Medical oncologist are routinely involved in the care of patients who are diagnosed with non small cell lung cancer. No matter what stage (I-IV), our practice at Beth Israel is that a medical oncologist should be involved at least initially in all patients diagnosed with lung cancer.