Approach to the patient with cancer

Although nivolumab (anti-programmed cell death-1 antibody) is a promising approach for advanced gastric cancer (AGC), the response rate remains limited. The aim of this multicenter retrospective study was to determine if clinical features could serve as prognostic factors of the efficacy of nivolumab in patients with AGC.

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Objectives: To assess results of transanal total mesorectal excision laparoscopic surgery for treatment of the middle and low rectal cancer. Subjects and method: Clinical intervention, prospective, follow-up study without comparison in 45 patients with middle and low rectal cancer underwent transanal total mesorectal excision in Gastrointestinal Surgery Department, 108 Millitary Central Hospital, from July 2017 to August 2018.

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Theb-amyloid peptide (Ab) is a major component of toxic amyloid plaques found in the brains of patients with Alzheimer’s disease.Abis liberated by sequential cleavage of amyloid precursor protein (APP) byb-andc-secre-tases.The level of Abdepends directly on the hydrolytic activity ofb-secretase.Therefore, b-secretase is an excel-lent target for drug design.An approach based on RNA-cleaving ribozymes was developed to control expression ofb-secretase.

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Radical Prostatectomy The goal of radical prostatectomy is to excise the cancer completely with a clear margin, to maintain continence by preserving the external sphincter, and to preserve potency by preserving the autonomic nerves in the neurovascular bundle. Radical prostatectomy is advised for patients with a life expectancy of 10 years and is performed using a retropubic, perineal, or laparoscopic approach. Outcomes can be predicted using postoperative nomograms that consider pretreatment factors and the pathologic findings at surgery. PSA failure is defined as a value above 0.

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One approach—so-called neoadjuvant chemotherapy—involves the administration of adjuvant therapy before definitive surgery and radiation therapy. Because the objective response rates of patients with breast cancer to systemic therapy in this setting exceed 75%, many patients will be "downstaged" and may become candidates for breast-conserving therapy. However, overall survival has not been improved using this approach.

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Superior Sulcus or Pancoast Tumors Non-small cell carcinomas of the superior pulmonary sulcus producing Pancoast's syndrome appear to behave differently than lung cancers at other sites and are usually treated with combined radiotherapy and surgery. Patients with these carcinomas should have the usual preoperative staging procedures, including mediastinoscopy and CT and PET scans, to determine tumor extent and a neurologic examination (and sometimes nerve conduction studies) to document involvement or impingement of nerves in the region.

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Principles of Chemotherapy Medical oncology is the subspecialty of internal medicine that cares for and designs treatment approaches to patients with cancer, in conjunction with surgical and radiation oncologists. The core skills of the medical oncologist include the use of drugs that may have a beneficial effect on the natural history of the patient's illness or favorably influence the patient's quality of life. In general, the curability of a tumor is inversely related to tumor volume and directly related to drug dose.

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Death and Dying The most common causes of death in patients with cancer are infection (leading to circulatory failure), respiratory failure, hepatic failure, and renal failure. Intestinal blockage may lead to inanition and starvation. Central nervous system disease may lead to seizures, coma, and central hypoventilation. About 70% of patients develop dyspnea preterminally. However, many months usually pass between the diagnosis of cancer and the occurrence of these complications, and during this period the patient is severely affected by the possibility of death. ...

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Effusions Fluid may accumulate abnormally in the pleural cavity, pericardium, or peritoneum. Asymptomatic malignant effusions may not require treatment. Symptomatic effusions occurring in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor. Symptomatic effusions occurring in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy of at least 6 months. Pleural effusions due to tumors may or may not contain malignant cells.

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Pain Pain occurs with variable frequency in the cancer patient: 25–50% of patients present with pain at diagnosis, 33% have pain associated with treatment, and 75% have pain with progressive disease. The pain may have several causes. In ~70% of cases, pain is caused by the tumor itself—by invasion of bone, nerves, blood vessels, or mucous membranes or obstruction of a hollow viscus or duct.

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The recognition and treatment of depression are important components of management. The incidence of depression in cancer patients is ~25% overall and may be greater in patients with greater debility. This diagnosis is likely in a patient with a depressed mood (dysphoria) and/or a loss of interest in pleasure (anhedonia) for at least 2 weeks. In addition, three or more of the following symptoms are usually present: appetite change, sleep problems, psychomotor retardation or agitation, fatigue, feelings of guilt or worthlessness, inability to concentrate, and suicidal ideation.

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Making a Treatment Plan From information on the extent of disease and the prognosis and in conjunction with the patient's wishes, it is determined whether the treatment approach should be curative or palliative in intent. Cooperation among the various professionals involved in cancer treatment is of the utmost importance in treatment planning.

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Tumor markers may be useful in patient management in certain tumors. Response to therapy may be difficult to gauge with certainty. However, some tumors produce or elicit the production of markers that can be measured in the serum or urine and, in a particular patient, rising and falling levels of the marker are usually associated with increasing or decreasing tumor burden, respectively. Some clinically useful tumor markers are shown in Table 77-5.

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Defining the Extent of Disease and the Prognosis The first priority in patient management after the diagnosis of cancer is established and shared with the patient is to determine the extent of disease. The curability of a tumor usually is inversely proportional to the tumor burden. Ideally, the tumor will be diagnosed before symptoms develop or as a consequence of screening efforts (Chap. 78). A very high proportion of such patients can be cured.

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Cancer Around the World In 2002, 11 million new cancer cases and 7 million cancer deaths were estimated worldwide. When broken down by region of the world, ~45% of cases were in Asia, 26% in Europe, 14.5% in North America, 7.1% in Central/South America, 6% in Africa, and 1% in Australia/New Zealand (Fig. 77-3). Lung cancer is the most common cancer and the most common cause of cancer death in the world. Its incidence is highly variable, affecting only 2 per 100,000 African women but as many as 61 per 100,000 North American men. Breast cancer is the second...

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Harrison's Internal Medicine Chapter 77. Approach to the Patient with Cancer Approach to the Patient with Cancer: Introduction The application of current treatment techniques (surgery, radiation therapy, chemotherapy, and biological therapy) results in the cure of nearly two of three patients diagnosed with cancer. Nevertheless, patients experience the diagnosis of cancer as one of the most traumatic and revolutionary events that has ever happened to them.

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