CANCER Report
CANCER Report
CANCER Report
CANCER
Large group of diseases characterized by DNA damage that
causes abnormal cell growth and development.
Initiation
Exposure of normal cells to
carcinogen
Promotion
Exposure of mutated cells
to factors that enhance its
growth
Progression
Further genetic changes
leading to increased cell
proliferation
Seven Warning Signs
1. Carcinoma in situ
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
1. Invasive Cancer
Molecular Subtypes
Luminal A
(ER+ &/or PR+, HER2-)
Luminal B
● Most common subtype
(ER+ &/or PR+, HER2+)
● Less aggressive
● Similar to Luminal A
● Lower histological grade
● More frequently ER+/PR-
● Good prognosis
● Worse outcome than Luminal A
● Hormone responsive
● Associated with increasing age
HER2+
Basal-like
(ER-)
(Triple negative, cytokeratin 5/6+ &/or
● Less common, highly aggressive
EGFR+)
subtype
● Aggressive subtype
● High grade histology
● High grade histology, and high
● Risk at younger age (<40)
mitotic rate
greater than luminal subtypes
● Risk at younger age (<40)
● Outcome improved with
● More likely premenopausal
therapies aimed at the HER2
African American women
protein
Pathophysiology
Pathophysiology
Cancer Type Sites for Metastasis
Breast Axillary lymph nodes, lung, liver,
bone, brain
Early Detection
Early Detection
Screening Recommendation
Mammogram Every year for ages 40 and older
Clinical breast exam Every year for ages 40 and older
Every 3 years for ages 20 to 39
Self breast exam Monthly for ages 20 and older
Diagnosing
Diagnosing
TNM Staging
T<1cm 90%
Staging
T> 1-2cm 80-90%
IIB T2N1M0 5-10% worse than IIA and based on node status
Stage 0 Stage 0 cancer means that the cancer is limited to the inside of the milk duct and is a non-invasive cancer. The
treatment approaches for these non-invasive breast tumors are often different from the treatment of invasive breast
cancer. Stage 0 breast tumors include ductal carcinoma in situ (DCIS)
Stage 1 These breast cancers are still relatively small and either have not spread to the lymph nodes or have only a tiny area of
cancer spread in the sentinel lymph node (the first lymph node to which cancer is likely to spread).
Stage 2 These breast cancers are larger than stage I cancers and/or have spread to a few nearby lymph nodes.
Stage 3 These tumors are larger or are growing into nearby tissues (the skin over the breast or the muscle underneath), or they
have spread to many nearby lymph nodes.
Stage 4 Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. Treatment for
stage IV breast cancer is usually a systemic (drug) therapy.
Treatment Guideline
Breast Cancer Treatments
Breast Cancer Treatments
Chemotherapy Description
Stage (D)
Open biopsy (B) Y Excision -
LCIS
? (E) Observation
Y
0? N
Y Adjuvant
Lumpectomy with ER/PR
Positive Y Hormonal TX
DCIS nodal sampling or +?(F)
cancer? (C)
MRM
N
N
Observe
Refer
Stage (D)
Ax Y Y
ER/PR/HER2 Adjuvant
LN+? Chemotherapy
Y Breast (-)? (F)
I or (H)
Conservation
II? or MRM (G)
N N
Y
Adjuvant Chemotx ±
Premenopausal? Hormonal Tx ± Trastuzumab N
Positive Observe
Tumor size >= 1.0 Y margin?
cm or with N
unfavorable
prognostic factors Y
Menopausal Hormonal ± Adjuvant
Chemotx ± Trastuzumab
N Adjuvant
Radiotherapy (I)
Observe
Treatment: Early Breast Cancer
I. Local-Regional Therapy
● Surgery alone can cure most patients with in situ cancers and approximately one-half of those with stage II
cancers.
● Breast-conserving therapy (BCT) is appropriate primary therapy for most women with stage I and II disease;
it is preferable to modified radical mastectomy because it produces equivalent survival rates with cosmetically
superior results. BCT consists of lumpectomy (i.e., excision of the primary tumor and adjacent breast tissue)
followed by radiation therapy (RT) to prevent local recurrence.
● RT is administered to the entire breast over 4 to 6 weeks to eradicate residual disease after BCT.
Reddening and erythema of the breast tissue with subsequent shrinkage of total breast mass are minor
complications associated with RT.
● Simple or total mastectomy involves removal of the entire breast without dissection of underlying muscle or
axillary nodes. This procedure is used for carcinoma in situ where the incidence of axillary node involvement is
only 1% or with local recurrence following breast conservation therapy.
● Axillary lymph nodes should be sampled for staging and prognostic information. Lymphatic mapping with
sentinel lymph node biopsy is a new, less invasive alternative to axillary dissection; however, the procedure is
controversial because of the lack of long-term data.
Treatment: Early Breast Cancer
II. Systemic Adjuvant Therapy
● Systemic adjuvant therapy is the administration of systemic therapy following definitive local therapy (surgery,
radiation, or both) when there is no evidence of metastatic disease but a high likelihood of disease recurrence.
● Chemotherapy, hormonal therapy, or both result in improved disease-free survival and/or overall survival (OS)
for all treated patients.
● The National Comprehensive Cancer Network practice guidelines reflect the trend toward the use of
chemotherapy in all women regardless of menopausal status, and the addition of hormonal therapy in all
women with receptor-positive disease regardless of age or menopausal status.
● Genetic tests are being prospectively validated as decision-support tools for adjuvant chemotherapy in node-
negative patients to identify characteristics of the primary tumor that may predict for the likelihood of
metastases and death.
Agents Used in Adjuvant Systemic Therapy
● Taxanes: Among the most active and commonly used chemotherapeutic agents for the treatment of early stage
breast cancer
● Anthracyclines: Used in the treatment of early stage breast cancer for decades, although concerns regarding
anthracycline-associated cardiotoxicity or leukemogenic potential remain
● Pertuzumab: Use in combination with trastuzumab and chemotherapy as adjuvant treatment of patients with HER2-
positive early breast cancer at high risk of recurrence
● Trastuzumab: Used in the (neo)adjuvant treatment in patients with HER2-positive breast cancer
● Tamoxifen: Used in the treatment of estrogen receptor (ER) ̶ positive breast cancer; decreases estrogen's ability to
stimulate existing micrometastases or dormant cancer cells
● Aromatase inhibitors (AIs): Inhibit aromatase, the enzyme responsible for converting other steroid hormones into
estrogen
Neoadjuvant chemotherapy
The best candidates for neoadjuvant chemotherapy are patients with ER-negative and/or HER2-positive expressing
tumors whose pathologically complete response (pCR) rates can approach 65% and predict long-term survival. Patients
with ER-positive, HER2-negative locally advanced breast cancer (LABC) are unlikely to achieve a pCR from currently
available chemotherapy.
Adjuvant Treatment Guidelines
Stage (D)
Chemotherapy
with RT
Treatment: Locally Advanced Breast Cancer (III)
● Neoadjuvant or primary chemotherapy is the initial treatment of choice.
● Benefits include rendering inoperable tumors resectable and increasing the rate of BCT.
● Primary chemotherapy with either an anthracycline- or taxane-containing regimen is recommended. The use of
trastuzumab with chemotherapy is appropriate for patients with HER2-positive tumors.
● Surgery followed by chemotherapy and adjuvant RT should be administered to minimize local recurrence.
● Cure is the primary goal of therapy for most patients with Stage III disease.
Stage (D)
● Endocrine therapy is the treatment of choice for patients who have hormone receptor-positive
metastases in soft tissue, bone, pleura, or, if asymptomatic, viscera. Compared with chemotherapy,
endocrine therapy has an equal probability of response and a better safety profile.
● Patients are sequentially treated with endocrine therapy until their tumors cease to respond, at which
time chemotherapy can be given.
● Historically, the choice of an endocrine therapy was based primarily on toxicity and patient preference
but study results have led to changes in MBC treatment.
● Aromatase inhibitors reduce circulating and target organ estrogens by blocking peripheral conversion
from an androgenic precursor, the primary source of estrogens in postmenopausal women. Newer
agents are more selective and better tolerated than the prototype, aminoglutethimide.Anastrozole,
letrozole, and exemestane are approved as second-line therapy; anastrozole and exemestane have
been shown to improve OS and time to progression compared with progestins. As first-line therapy,
anastrozole and letrozole increase time to progression and are better tolerated compared with
tamoxifen.
Treatment: Metastatic Breast Cancer (IV)
● Tamoxifen is the antiestrogen of choice in premenopausal women whose tumors are hormone-
receptor positive, unless metastases occur within 1 year of adjuvant tamoxifen. Maximal beneficial
effects do not occur for at least 2 months. In addition to the side effects described for adjuvant
therapy, tumor flare or hypercalcemia occurs in approximately 5% of patients with MBC.
● Toremifene has similar efficacy and tolerability as tamoxifen and is an alternative to tamoxifen in
postmenopausal patients. Fulvestrant is a second-line intramuscular agent with similar efficacy and
safety when compared to anastrozole in patients who progressed on tamoxifen. Ovarian ablation
(oophorectomy) is considered by some to be the endocrine therapy of choice in premenopausal
women and produces similar overall response rates as tamoxifen. Medical castration with an LHRH
analog, goserelin, leuprolide, or triptorelin, is a reversible alternative to surgery.
● Progestins are generally reserved for third-line therapy. They cause weight gain, fluid retention, and
thromboembolic events.
Treatment: Metastatic Breast Cancer (IV)
II. Chemotherapy
● Chemotherapy is preferred to endocrine therapy for women with hormone receptor-negative tumors; rapidly
progressive lung, liver, or bone marrow involvement; or failure of endocrine therapy.
● The choice of treatment depends on the individual. Agents used previously as adjuvant therapy can be
repeated unless the cancer recurred within 1 year.
● Single agents are associated with lower response rates than combination therapy, but time to progression and
OS are similar. Single agents are better tolerated, an important consideration in the palliative metastatic
setting.
● Combination regimens produce objective responses in approximately 60% of patients previously unexposed to
chemotherapy, but complete responses occur in less than 10% of patients. The median duration of response
is 5 to 12 months; the median survival is 14 to 33 months.
Treatment: Metastatic Breast Cancer (IV)
II. Chemotherapy
● Anthracyclines and taxanes produce response rates of 50% to 60% when used as first-line therapy for MBC.
Single agent capecitabine, vinorelbine, or gemcitabine have response rates of 20% to 25% when used after an
anthracycline and a taxane.
● Trastuzumab, a monoclonal antibody that binds to HER2, produces response rates of 15% to 20% when used
as a single agent and increases response rates, time to progression, and OS when combined with
chemotherapy. It has been studied in doublet (taxane-trastuzumab; vinorelbinetrastuzumab) and triplet
(trastuzumab-taxane-platinum) combinations but the optimum regimen is unknown.
● Trastuzumab is well tolerated, but the risk of cardiotoxicity is 5% with single-agent trastuzumab and
unacceptably high in combination with an anthracycline.
● Lapatinib, a tyrosine kinase inhibitor that targets both HER2 and the epidermal growth factor receptor,
improved response rates and time to progression in combination with capecitabine, as compared to
capecitabine alone, in patients previously treated with an anthracycline, taxane, and trastuzumab. The most
common adverse events were rash and diarrhea.
● The role of bevacizumab, a monoclonal antibody targeted against vascular endothelial growth factor, in MBC
is currently not clearly defined.
NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is
appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the
intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is
appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is
appropriate.
Alkylating Agent Cyclophosphamide The mechanism of action of the active metabolites may involve
cross-linking of DNA, which may interfere with the growth of
normal and neoplastic cells.
Anti-Microtubular Docetaxel Inhibits cancer cell growth by promoting assembly and blocking
the disassembly of microtubules, thereby preventing cancer cell
division and leading to cell death.
Vinca Alkaloid Vinorelbine Vinorelbine is a semisynthetic vinca alkaloid that inhibits tubulin
polymerization during the G2 phase of cell division, thereby
inhibiting mitosis.
Tyrosine Kinase Inhibitor Lapatinib Lapatinib is a 4-anilinoquinazoline kinase that inhibits the
intracellular tyrosine kinase domains of epidermal growth factor
receptor (EGFR [ErbB1]) and HER2 (ErbB2).
Class Agent Action
Aromatase Inhibitor Anastrazole Significantly lowers serum estradiol concentrations by inhibiting the
conversion of adrenally generated androstenedione to estrone.
Aromatase Inhibitor Letrozole Letrozole is a nonsteroidal competitive inhibitor of the aromatase enzyme
system. It inhibits the conversion of androgens to estrogens.
Aromatase Inhibitor Exemestane Exemestane elicits irreversible steroidal aromatase inactivation by acting
as a false substrate for the aromatase enzyme. It binds irreversibly to the
aromatase enzyme active site, causing inactivation
Hormonal Therapy
Class Agent Action
Estrogen Receptor Tamoxifen* Tamoxifen is a nonsteroid with potent antiestrogenic effects in the breast;
Antagonist however, it may be an estrogen agonist in the uterus.
Monoclonal Antibody Bevacizumab (no longer approved by blocks the growth of new blood vessels that
the FDA Nov 2011) cancer cells depend on to grow and function.
Anemia Erythropoietin
NSCLC
● TSG Inactivation (Tumor Suppressor Gene)
● Oncogene Activation → EGFR activation
● Telomerase Activation
● Evasion of Apoptosis
○ Tumor Growth and Maintenance
● Angiogenesis
Pathophysiology
https://www.youtube.com/watch?v=J5UfBV18Bis
Signs
Computed Tomography (CT) Scan
• Features of Nodule → no calcium build up; rough edges and odd shapes
o Size → larger than normal since grows faster
o Density
▪ Solid
▪ Part-solid
• Abnormal Lung Tissue → inflammation, scarring or both
According to the latest WHO data published in 2017 Lung Cancers Deaths in Philippines
reached 11,365 or 1.84% of total deaths. The age adjusted Death Rate is 16.99 per
100,000 of population ranks Philippines #72 in the world.
Staging (SCLC)
1. Limited Stage
○ Stage I to III of NSCLC excluding T3-T4
○ found on one side of the chest, involving only one part of the lung and the nearby
lymph nodes
2. Extensive Stage
○ Stage IV or T3-T4
○ cancer has spread to other regions of the lungs, or other parts of the body
TNM Classification
❏ American Joint Committee on
Cancer staging system → used to
stage lung cancer
❏ T, N, and M → used to describe
areas of cancer growth
❏ T - tumor
❏ How large or where the
primary tumor is grown
❏ N - nodes
❏ How far the cancer has
spread through the lymph
❏ M - metastasis
TNM Classification
Staging (NSCLC)
○ Stage I - located only in the lungs
○ Stage II - in the lung and nearby lymph
nodes
○ Stage III - found in the lungs and in the
lymph nodes in the middle of the chest;
locally advanced
■ IIIA - if the cancer spread to the lymph
nodes on the same side of the chest
where the cancer started
■ IIIB - if the cancer has spread to the
lymph nodes on the opposite side of
the chest or above the collar bone
○ Stage IV - most advanced stage; when the
cancer has spread to both lungs, to fluid in
the area around the lungs, or to another
part of the body, such as the liver or other
organs.
Diagnostic Tests (NSCLC)
❖ Blood Tests
➢ Complete Blood Count (CBC)
➢ Chemistry Profile
❖ Imaging Test
➢ Diagnostic CT
➢ FDG PET/CT
➢ Brain MRI
➢ MRI of spine and thoracic inlet
❖ Bronchoscopy
❖ Lung Function Test
FDG PET/CT
❖ Biopsy
➢ TTNA
➢ Mediastinoscopy
➢ EBUS-TBNA
➢ EUS-FNA
➢ Thoracentesis
➢ Pericardiocentesis
➢ Thoracoscopy
Cancer lab test
● Histologic typing
● Biomarker testing
○ Overactive EGFR mutation
○ ALK gene rearrangement
○ ROS1 gene rearrangement
○ BRAF V600E mutation
Lung CA
suspect (A)
No other Y No Y Close follow
CA site? CT Scan (C)
Chest X-ray Mass? up; Refer
PAL (B) N N
Manage by
No Y
case; Refer
Mass?
N
Centrally Y Bronchoscopy w/
located? biopsy or cytology
(D)
N
Peripheral Y Percutaneous
location? FNAB (E)
Cancer? Y
N A
(G)
Enlarged Y
neck Biopsy N
nodes?
Highly Y
N suspect Radio tx
Pleural Y Thoracentesis w/ cancer?
effusion? cytology (F)
No case; Refer
Mass?
N
Centrally Y Bronchoscopy w/
located? biopsy or cytology
(D)
N
Peripheral Y Percutaneous
location? FNAB (E)
Cancer? Y
N A
(G)
Enlarged Y
neck Biopsy N
nodes?
Highly Y
N suspect Radio tx
Pleural Y Thoracentesis w/ cancer?
effusion? cytology (F)
N
Close follow-
N Refer up
Highly suspect Y
Radio tx
cancer?
N
Close
Refer
surveillance
A
Positive lung
cancer? (G)
Y Stage Y Y
Not Rt +/- chemo
SCLC? T1T2N0M
operable?
0? (H)
N N
Adjuvant Rt (K)
Lobectomy (J) and/or Chemo (L)
Stage Y
T3T4N1- Chemo +/- Rt
3M0? (H)
N
Palliative
Metastatic? Chemo +/- Rt
Management of Small Cell Lung Cancer
1. Chemotherapy
○ Typical treatment for SCLC
○ SCLC has usually already spread by the time it is found, so other treatments such as surgery
or radiation therapy would not reach all areas of cancer
● For people with limited stage SCLC, chemo is often given along with radiation therapy.
This is known as chemoradiation.
● For people with extensive stage SCLC, chemo alone is usually the main treatment
2. Immunotherapy
○ Nivolumab (Opdivo)
● targets PD-1, a protein on T cells that normally helps keep these cells from attacking
other cells in the body. By blocking PD-1, this drug boosts the immune response against
SCLC shrinking tumor cells.
● It is used in people with advanced small cell lung cancer whose cancer continues to
grow after at least two previous systemic treatments including cisplatin or carboplatin.
Management of Small Cell Lung Cancer
3. Radiation Therapy
○ uses high-energy rays (such as x-rays) or particles to kill cancer cells
○ Can be given with chemotherapy in limited stage of SCLC
○ can also be given after the chemo is finished
● done for patients with extensive stage disease
● or it can be used for people with limited stage as an alternative to chemoradiation
○ can be given to the brain to help lower the chances of problems from cancer spread there.
● prophylactic cranial irradiation
■ most often used to treat people with limited stage SCLC, but it can also help some
people with extensive stage SCLC
○ used to shrink tumors to relieve (palliate) symptoms of lung cancer such as pain, bleeding,
trouble swallowing, cough, shortness of breath, and problems caused by spread to other
organs such as the brain.
Management of Small Cell Lung Cancer
4. Surgery
○ rarely used as part of the main treatment
○ Early-stage cancer
● If cancer is found as only a single lung tumor, with no spread to lymph nodes or other
organs
○ followed by additional treatment
○ Types of Surgery
● Pneumonectomy
● Lobectomy
● Segmentectomy or wedge resection
● Sleeve resection
Management of Small Cell Lung Cancer
5. Palliative Procedure
○ aimed at relieving symptoms and improving a person’s quality of life
○ Treating an airway blocked by a tumor
■ Photodynamic therapy (PDT)
■ Laser therapy
■ Stent placement
○ Treating fluid buildup in the area around the lung
■ Thoracentesis
■ Pleurodesis
■ Catheter placement
○ Treating fluid buildup around the heart
■ Pericardiocentesis
■ Creating a pericardial window
TREATMENT GUIDELINE FOR SMALL CELL LUNG CANCER
Chemotherapy for SCLC
➔ As primary or adjuvant therapy
Subsequent chemotherapy
➔ Clinical Trial preferred
Chemotherapy for SCLC
Relapse ≤6 mo, PS 0-2:
➢ topotecan PO or IV
➢ irinotecan
➢ paclitaxel
➢ docetaxel
➢ temozolomide
➢ nivolumab ± ipilimumab
➢ vinorelbine
➢ oral etoposide
➢ gemcitabine
➢ cyclophosphamide/doxorubicin/vincristine (CAV)
➢ bendamustine (category 2B)
Extensive Stage:
➢ Consolidative thoracic RT is beneficial for selected patients that responds to
systemic therapy
○ well-tolerated
Radiotherapy for SCLC
Prophylactic Cranial Irradiation (PCI)
➢ Preferred dose: 25 Gy in 10 daily fractions
○ Shorter course (20 Gy in 5 fractions) for selective extensive-stage
disease
➢ Not recommended in patients with poor performance status or impaired
neurocognitive functioning
Brain Metastases
➢ Should be treated with whole brain radiation therapy (WBRT) rather than
stereotactic radiotherapy/radiosurgery (SRT/SRS) alone
➢ Recommended dose: 30 Gy in 10 daily fractions
SCLC?
NSCLC Y Y Y
Surgery (J) Positive
Stage I? Operable? Rt
margins?
(I)
N N N
Chemo +/- Close follow-
RT (L) up
Y Y Y
Stage Surgery Positive
Operable? Rt
II/III? margins?
N N
Chemo +/- Close follow-
Stage IV RT (L) up
Y Y
Single site Palliative
Operable?
metastasis? Surgery Chemo +/- Rt
N N
Lung tumor Stage IIA No cancer in the margin start survivorship plan
and lymph chemotherapy
node surgery
Cancer in the margin another surgery (preferred)
chemoradiation
Radiation chemotherapy
therapy
Treatment for Stage II NSCLC (T3 superior sulcus tumor)
Treatment
Surgery + chemotherapy
Chemoradiation Durvalumab
Induction chemotherapy ± radiation therapy Adjuvant radiation (if not received before) ± chemotherapy
Chemoradiation Durvalumab
Survivorship plan (Stage III)
Treatment for Stage IV NSCLC
Overactive EGFR mutation
Dabrafenib + trametinib
Pembrolizumab
Social History
● Employed full-time as an accountant
● Married with 2 children
● Youngest son is about to graduate from US Air Force Academy
Initial Treatment
● Patient was started on chemotherapy with pemetrexed and a platinum every
three weeks (with vitamin B12 and folic acid supplementation)
Case
Physical Exam/Review of Symptoms at Progression
● ECOG PS 1
● No palpable lymph nodes
● Decreased breath sounds in right upper lobe
Treatment Plan
● Because the patient has progressive disease with symptoms, a discussion was
had with the patient regarding his options, which included immunotherapy as
well as docetaxel with ramucirumab. After an explanation of both options,
including the available data, the patient elects to receive docetaxel and
CYRAMZA.
Case
Why adding CYRAMZA may be appropriate
● Patient presents with rapidly progressing disease†
● Patient has a good performance status (ECOG PS 1)
● Patient has aggressive disease, with progressive disease as best response to
initial therapy
● Patient wants a chance to see a response to treatment and slow progression
● He is determined to do all he can to try and continue working to support his
family and to be able to see his son graduate from the Air Force Academy
References
American Cancer Society. (2018). Treating Small Cell Lung Cancer. Retrieved from https://www.cancer.org/cancer/small-cell-lung-
cancer/treating.html
American Cancer Society. (2018). What Causes Small Cell Lung Cancer? Retrieved from https://www.cancer.org/cancer/small-cell-lung-
cancer/causes-risks-prevention/what-causes.html
American Joint Committee on Cancer. (2009). Lung Cancer Staging. Retrieved from http://cancerstaging.org/references-
tools/quickreferences/documents/lungmedium.pdf
Dholaria, B., Hammond, W., Shreders, A., & Lou, Y. (2016). Emerging therapeutic agents for lung cancer. Journal of hematology & oncology, 9(1),
138. https://doi.org/10.1186/s13045-016-0365-z
Haymarket Media, Inc. (2014). Lung Cancer Treatment Regimens. Retrieved from
http://media.chemotherapyadvisor.com/documents/32/lungcancer_7894.pdf
Lung Foundation Australia. (2014). Types of Lung Cancer. Retrieved from https://lungcancernetwork.com.au/about-lung-cancer/types-of-lung-cancer/
Mechanisms in Medicine. (2012, March 14). The Pathophysiology of Non-small Cell Lung Cancer. Retrieved from
https://www.youtube.com/watch?v=J5UfBV18Bis
Nasser, N. J. (2010). The Best Oncologist TM. Retrieved from
http://www.thebestoncologist.com/Cancer_Diseases/Lung_Cancer/Staging_of_Lung_Cancer.html
National Comprehensive Cancer Network. (2016, September 15). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Small Cell
Lung Cancer. Retrieved from https://www2.tri-kobe.org/nccn/guideline/lung/english/small.pdf
National Comprehensive Cancer Network. (2018). Non-small cell lung cancer. Retrieved from https://www.nccn.org/patients/guidelines/lung-
nsclc/files/assets/common/downloads/files/nsclc.pdf
Philippine Cancer Society. (2014). Tertiary prevention of cancer: Clinical treatment guidelines. Retrieved from http://www.philcancer.org.ph/wp-
content/uploads/2014/04/PCSI-Tertiary-Cancer-Treatment-Guidelines.pdf
Philippine Society of Medical Oncology. (2005). CPM 8th Breast Cancer and Lung Cancer. Retrieved from
https://www.thefilipinodoctor.com/cpm_pdf/CPM8th Breast Cancer and Lung Cancer.pdf
World Health Organization. (2018). Cancer. Retrieved from http://www.who.int/cancer/en/
World Health Organization. (2015). Globocan. Retrieved from http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx?cancer=lung
World Health Rankings. (2017). Lung Cancers in Philippines. Retrieved from http://www.worldlifeexpectancy.com/philippines-lung-cancers
References
Fauci, A.. et al. (2008). Harrison’s Principle of Internal Medicine (17th edition). United States of America: The McGraw-Hill Companies Inc.
Goldman, L., Schaffer, A. (2012). Goldman’s Cecil Medicine (24th edition). Philadelphia, PA: Elsevier Saunders.
Gradishar, W. MD et al., (2017). NCCN Guidelines Insight. Journal of the National Comprehensive Cancer Network. (15)4. p. 433
Philippine Cancer Society (2015). Tertiary Prevention of Cancer: Clinical Treatment Guidelines. Retrieved from http://www.philcancer.org.ph/wp-
content/uploads/2014/04/PCSI-Tertiary-Cancer-Treatment-Guidelines.pdf
Wells, B. et al. (2009). Pharmacotherapy Handbook (7th edition). United States of America: The McGraw-Hill Companies Inc.