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At the heart of general practice since 1960

Practical lowdon on... Cancer prognosis and survival

The role of the GP in a follow-up review

• Check the patient has as much

information about the cancer as they want. Sensitivity and respect for individual wishes are fundamental in the communication process. Prognostic information needs to

relate to that individual and alters for each patient with the stage of the illness. Patients and relatives prefer the doctor to:

– play it straight

– stay the course

– give time

– show they care

– make it clear

– pace information1.

• Check the avenues of communication are clear to both GP and patient; specifically that a key worker has been identified. For those cancers where such a post exists this is likely to be a specialist nurse.

• Inquire about the patient's emotional state. Distress that is more than an expected reaction to the diagnosis may need specific treatment.

• Check the impact the diagnosis and the patient's condition is having on the family. When the patient is unwell or the prognosis is poor, try to see the carer on their own.

• Encourage the patient to understand and manage their own care and recommend

local and national support organisations (see boxes). Patients value contact with

survivors of similar cancers.

• Move to the inauguration of palliative care early, when it becomes apparent that treatment will not be curative.

Breast cancer

Women with breast cancer may die from the disease even after a remission of over five years. This excess mortality over their contemporaries is present even 20 to 40 years after diagnosis and initial treatment2. Survival is best if the tumour is:

• small (less than 2cm): five-year survival 95 per cent; with larger tumours (more than 2cm) the five-year survival is 80 per cent;

• tubular or mucinous;

• low-grade (well differentiated); high-grade (poorly differentiated) tumours carry

poorer prognosis;

• oestrogen-receptor positive as they are more likely to respond to hormone therapy.

Young women (under the age of 35) tend to develop aggressive tumours with a five-year survival of less than 50 per cent. For

a guide to staging and prognosis, see box

below centre.

Likely presentations of recurrent disease (see box, far right)

• Nodules in the skin or in the scar

• Nodes in the axilla or neck

• Contralateral breast cancer

• Bone pain, especially spinal

• Cough or breathlessness from pulmonary metastases

• Constitutional symptoms secondary to hypercalcaemia (lassitude, anorexia,

constipation, nausea)

• Neurological or behavioural problems

secondary to brain metastases

• Anaemia from marrow infiltration

Support organisations

• Breast Cancer Care, Kiln House, 210 New Kings Road, London SW6 4NZ. Helpline: 0808 800 6000. Tel. 020 7384 2984. Fax: 020 7384 3387. E-mail: info@breastcancercare.org.uk. Online: www.breastcancercare.org.uk.

• Breast Cancer Care (Scotland), 2nd Floor, 40 St Enoch Square, Glasgow, G1 4DH. Tel. 0845 0771 892. Fax: 0141 221 9499. E-mail: sco@breastcancercare.org.uk. Online: www.breastcancercare.org.uk

• Lymphoedema Support Network, St Luke's Crypt, Sydney Street, London SW3 6NH. Tel. 0207 351 4480. Online:

www.lymphoedema.org/lsn/index.html

Colorectal cancer

The overall five-year survival is around 40 per cent.

Staging and prognosis

Survival rates may be improved with adjuvant chemotherapy (five-fluorouracil (5FU) and folinic acid (FA)) as follows:

• Stage 2 – uncertain effect; trials in progress

• Stage 3 – improves absolute five-year

survival by 10 per cent

• Stage 4 – response in 20 to 30 per cent, with improvement in median survival of six months and symptom-free period improved from two months to 10 months

Oxaliplatin and irinotecan, added to 5FU/FA, improve response rates further.

Follow-up

• Some 80 per cent of recurrences occur within the first two years after surgery and it is traditional to undertake more intensive follow-up during this period. However, the majority of local and distant recurrences are symptomatic at the time of discovery and patients may wait for their follow-up appointments to disclose symptoms.

• Only about 30 per cent of patients with

recurrent disease are suitable for surgery and survival results are poor.

• Although the responsibility for follow-up is usually with specialists, the results of one RCT indicate no greater mortality or

morbidity in those followed up in general practice.

• Patients with colorectal cancer have a

predisposition to further adenomas and a second primary cancer in the remaining large bowel.

• Colonoscopy is recommended:

– after resection to establish if polyps or further primary cancer are present;

– at five-yearly intervals, if they are polyp free, until the age of 70;

– more frequently if five or more

adenomas are found.

• Refer if there are any symptoms of

primary bowel cancer – a mass, rectal

bleeding, a change in bowel habit to looser stools or increased frequency or iron

deficiency anaemia without obvious cause.

• Consider checking carcinoembryonic antigen (CEA) levels in those patients who had a raised CEA at diagnosis, unless it is

being checked by the specialist clinic. Refer if the level is rising. However, there is no

evidence that the lead time provided by monitoring confers any survival benefit.

• Examine the liver for metastases.

Guidelines

• Schofield JH, Steele RJ. Guideline for follow up after resection of colorectal cancer. Gut 2002; 51(suppl V): v3-v5.

• NICE. Improving outcomes in colorectal cancers – manual update. London: NICE; 2004. Online: www.nice.org.uk.

Support organisations

Colostomy Association, 15 Station Road, Read-ing, Berkshire RG1 1LG. Tel. 0800 587 6744.

Online: www.colostomyassociation.org.uk

Prostate cancer

Histological grading (Gleason scores) – these values range from two to 10, where two corresponds to a well-differentiated tumour and 10 corresponds to a very poorly differentiated tumour.

Patients with low-grade lesions (two to four) have 15-year survival of about 94 per cent, whereas those with higher-grade lesions (seven to 10) have a 15-year survival of 15-50 per cent.

Most men diagnosed with prostate cancer die from other causes. The predicted 15-year cancer mortality with a Gleason score of six is around 10 per cent, whereas mortality from other causes is around 60 per cent.

Radical treatment is likely to have only

a small impact on survival, with considerable long-term morbidity.

Watchful waiting is often done in those who:

• are over 70 years of age;

• have low Gleason scores (seven or

below);

• have co-morbidity and a life expectancy of less than 15 years.

Hormonal therapy and palliative radiotherapy may be offered if the patient develops symptomatic disease.

Active surveillance is performed to tailor treatment to the individual:

• in younger patients who are fit for radical surgery;

• with early-stage disease (T1-2, low Gleason scores =7, PSA<>

Patients are frequently monitored with PSA testing, DRE and repeat biopsies. Patients with rapid doubling of PSA with an increased Gleason score may be offered radical treatment.

Radical prostatectomy has a disease-free survival rate at 10 years of about 75 per cent. However, incontinence occurs in around 15 per cent and impotence in 30 per cent with modern techniques. Urethral stricture occurs in around 5 per cent.

Radiotherapy may be performed on its own but increasingly is combined with three to six months of hormonal therapy followed by three years' hormonal therapy. Acute side-effects of radiotherapy include fatigue, proctitis and increased frequency of bowel movements. Long-term side-effects are impotence in around 30 per cent and incontinence in <1 per="">

Brachytherapy (insertion of radioactive seeds or temporary implants) is most likely to be offered to patients with

• Gleason score =6, PSA <>

• a TNM score of T1-2

• minimal obstructive symptoms

• a small prostate volume.

Some 80 per cent are free of PSA relapse at five years and 70 per cent at 10 years. Side-

effects include impotence in 30 per cent, incontinence in 1 per cent, transient retention of urine and transient proctitis.

Likely presentations of recurrent disease

• Bone pain, pathological fracture and cord compression

• Anaemia and thrombocytopenia from marrow infiltration

• Haematuria and perineal pain

• Lymphoedema from nodal disease

• Obstructive uropathy

• Side-effects of treatment

• Bladder outflow problems

• Impotence

• Hot flushes from androgen withdrawal

• Gynaecomastia

Patient organisations

• The Prostate Cancer Charity, 3 Angel Walk, London W6 9HX. Tel. 020 8222 7622. Helpline: 0800 074 8383.

E-mail: info@prostate-cancer.org.uk

Online: www.prostate-cancer.org.uk.

• Prostate Cancer Support Association

Tel. 0845 601 0766.

E-mail: helpline@prostatecancer

support.info.

Online: www.prostatecancersupport.co.uk.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000.

Practical General Practice 5e is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

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