Oncologists

Please refer to cancerfor the biology of malignant disease, as well as a list of malignant diseases.

Oncology is the medical subspecialty dealing with the study and treatment of cancer. A physician who practices oncology is an oncologist. The term is from the Greekonkos (ονκος), meaning bulk, mass or tumor, and the suffix -ology, meaning "study of".

Oncologists may be divided based on the type of treatment provided.

• Surgical oncologists: who are surgeons who specialize in tumor removal.
• Medical oncologists: who deal with using medication or chemotherapyto treat cancer.
• Radiation oncologists: who specialize in the treatment of cancer with radiation, a process called radiotherapy.

Oncologists may also be categorized based on the patient type.

• Gynecologic oncologist: who specialize in the treatment of cancer in women. He/She can performs and give chemotherapy and assists in radiation therapy for these cancers in women.
• Pediatric oncologist: who specialize in the care of children with cancer.

N.B. In the UK, the majority of oncologists are known as Clinical Oncologists, and are fully qualified to practice both chemotherapy and radiotherapy. In most other countries these disciplines are more clearly segregated.

Oncology is concerned with:

• The diagnosisof cancer
• Therapy(e.g. surgery, chemotherapy, radiotherapyand other modalities)
• Follow-up of cancer patientsafter successful treatment
• Palliative careof patients with terminal malignancies
• Ethicalquestions surrounding cancer care
• Screeningefforts:
  • of populations, or
  • of the relatives of patients (in types of cancer that are thought to have a heritable basis, such as breast cancer).

The oncologist often coordinates the multidisciplinary care of cancer patients, which may involve physiotherapy, counselling, clincal genetics, to name but a few. On the other hand, the oncologist often has to liaise with pathologistson the exact biological nature of the tumorthat is being treated.

Diagnosis

The most important diagnostic tool remains the medical history: the character of the complaints and any specific symptoms (fatigue, weight loss, unexplained anemia, paraneoplastic phenomenaand other signs). Often a physical examination will reveal the location of a malignancy.

Diagnostic methods include:

• Biopsy, either incisional or excisional;
• Endoscopy, either upper or lower gastrointestinal, bronchoscopy, or nasendoscopy;
• X-rays, CT scanning, MRI scanning, ultrasoundand other radiological techniques;
• Scintigraphy, Positron emission tomographyand other methods of nuclear medicine;
• Blood tests, including Tumor markers, which can increase the suspicion of certain types of tumors or even be pathognomonic of a particular disease.

Apart from in diagnosis, these modalities (especially imaging by CT scanning) are often used to determine operability, i.e. whether it is surgicallypossible to remove a tumor in its entirety.

Generally, a "tissue diagnosis" (from a biopsy) is considered essential for the proper identification of cancer. When this is not possible, empirical therapy (without an exact diagnosis) may be given, based on the available evidence (e.g. history, x-rays and scans.)

Occasionally, a metastatic lump or pathological lymph node is found (typically in the neck) for which a primary tumor cannot be found. This situation is referred to as " carcinoma of unknown primary", and again, treatment is empirical, based on past experience of the most likely origin.

Therapy

It depends completely on the nature of the tumoridentified what kind of therapeutical intervention will be necessary. Certain disorders will require immediate admission and chemotherapy(such as ALLor AML), while others will be followed up with regular physical examination and blood tests.

Often, surgeryis attempted to remove a tumorentirely. This is only feasible when there is some degree of certainty that the tumor can in fact be removed. When it is certain that parts will remain, curative surgery is often impossible, e.g. when there are metastaseselsewhere, or when the tumor has invaded a structure that cannot be operated upon without risking the patient's life. Occasionally surgery can improve survival even if not all tumour tissue has been removed; the procedure is referred to as "debulking" (i.e. reducing the overall amount of tumour tissue). Surgery is also used for the palliativetreatment of some of cancers, e.g. to relieve biliary obstruction, or to relieve the problems associated with some cerebral tumours. The risks of surgery must be weighed up against the benefits.

Chemotherapyand radiotherapyare used as a first-line radical therapy in a number of malignancies. They are also used for adjuvanttherapy, i.e. when the macroscopic tumor has already been completely removed surgically but there is a reasonable statistical risk that it will recur. Chemotherapyand radiotherapyare commonly used for palliation, where disease is clearly incurable: in this situation the aim is to improve and prolong quality of life.

Hormonemanipulation is well established, particularly in the treatment of breast and prostate cancer.

There is currently a rapid expansion in the use of monoclonal antibodytreatments, notably for lymphoma(Rituximab), and breast cancer(Trastuzumab).

Vaccineand other immunotherapiesare the subject of intensive research.

Follow-up

A large segment of the oncologist's workload is the following-up of cancer patients who have been successfully treated. For some cancers, early identification of recurrence, with prompt treatment, can lead to better survival and quality of life. It depends on the nature of the cancer whether the follow-up lasts a number of years or remains "life long".

Palliative care

Although 50% of all cancer cases diagnosed achieve curation, a large number of cancer patients will die from the disease. There may be ongoing issues with symptom control associated with progressive cancer. These problems may include pain, nausea, anorexia, fatigue, immobility, and depression. Not all issues are strictly physical: personal dignity may be affected. Moral and spiritual issues are also important.

Whilst many of these problems fall within the remit of the oncologist, palliative carehas matured into a separate, closely allied speciality to address the problems associated with advanced disease. Palliative care is an essential part of the multidisciplinary cancer care team. Palliative care services may be less hospital-based than oncology, with nurses and doctors who are able to visit the patient at home.

Ethical issues

There are a number of recurring ethicalquestions and dilemmas in oncological practice. These include:

• What information to give the patient regarding disease extent/progression/prognosis.
• Entry into clinical trials, especially in the face of terminal illness.
• Withdrawal of active treatment.
• "Do Not Resuscitate" orders and other end of life issues.

These issues are closely related to the patients' personality, religion, culture, personal, and family life. The answers are rarely black and white. It requires a degree of sensitivity and very good communication on the part of the oncology team to address these problems properly.

Progress and research in oncology

There is a tremendous amount of research being conducted on all frontiers of oncology, ranging from cancer cell biology to chemotherapytreatment regimens and optimal palliative careand pain relief. This makes oncology an exciting and continuously changing field.

Therapeutic trials often involve patients from many different hospitals in a particular region. In the UK, patients are often enrolled in large studies coordinated by the Medical Research Council(MRC, www.mrc.ac.uk) or the European Organisation for Research and Treatment of Cancer(EORTC, www.eortc.be).

Complementary and Alternative therapies

See main article: Alternative medicine

Many cancer patients seek extra help from complementary and alternative therapies, which fall outside of conventional medicine. Most complementary therapies do not have a firm scientific or evidence base. However, some patients undoubtedly find complementary therapies helpful whilst they are undergoing conventional treatment.

Whilst most complementary therapies are harmless, they can be expensive. They may also be positively harmful if the patient forgoes conventional treatment altogether, in order to follow alternative regimens. Some alternative regimens are undoubtedly hazardous.

See also

• Alternative medicine
• Experimental cancer treatment
• List of oncology-related terms
• Performance status
• Important publications in oncology

References

• Vickers, A. Alternative Cancer Cures: "Unproven" or "Disproven"? CA Cancer J Clin 2004 54: 110-118. Full text online

External links

• American Cancer Society
• CancerBacup
• BC Cancer Agency
• Canadian Cancer Society
• Cancer Research UK
• International Agency for Research on Cancer
• MacMillan cancer relief
• National Cancer Institute
• Quackwatch guide to alternative cancer therapies
• Oncowiki: A Wiki based repository of Cancer Chemotherapy Regimens

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