1. General strategies of Cancer Treatment and evaluation of Response
Lodovico Balducci M.D.
Senior Member Emeritus
Moffitt Cancer Center
Tampa, FL

2. Clinical Case 83 year old man with cough
CT chest reveals a 3 cm mass Left Lower Lobe
Biopsy reveals an adenocarcinoma primary lung
PS 1; Lives alone, Independent ADL IADL

3. Clinical Case ROS: osteoarthritis, type II DM
PMH: MI age 65: CABPG; quit smoking
Colon cancer stage II age 71; surgery
Fracture right tibia age 19
Appendectomy age 41

4. Clinical case HB 13.8; Ca 10.1 Physical exam:
Lung moving 3 cm bilaterally
Deformity Left knee
Overweight

5. Strategy of cancer treatment
Effectiveness
Toxicity
Patient
Life expectancy
Treatment tolerance
Goals
CLINICAL DECISIONS
Cancer
Stage
Aggressiveness
Treatment Sensitivity
Tumor sanctuary

6. What do we want to know Stage: PET scan; CT scan, MRI
Sensitivity to treatment:
EGFR mutation
Ros Mutation
ALK mutation
RAS mutation
PDL1

7. What will we do with the information
Local disease: surgery; radiosurgery, ablation
Metastatic disease: systemic treatment according to sensitivity
Loco-regional disease: combination of local and systemic treatment
Brain metastases: may add radiation

8. Forms of cancer treatment
Loco-regional treatment
Systemic treatment
Surgery
Radiation Therapy
Loco-regional infusions
Local ablation
Hormonal therapy
Cytotoxic chemotherapy
Targeted therapy
Immune check-point inhibitors
Vaccines
Radio-isotopes

9. Examples of tumor markers
Lung: Ras, Ros, EGFR, ALK
Breast: hormone receptors, HER, Brca
Colorectal: Ras, MSI
All MSI?

10. New techniques to assess cancer
Circulating tumor cells
Liquid biosy
Molecular response in hematological malignancies

11. Adjuvant and neoadjuvant treatment
65 year old woman with a 2 cm tumor of the left breast
Has breast sparing surgery. LNs are negative
Tumor is positive for ER and PR and negative for HER
55 year old woman with a reddened mass of the left breast, adherent to the chest wall and edematous left upper extremity
No distant metastases; ER-PR-

12. Clinical case
79 year old man with colon cancer metastatic to the liver . Previously controlled with chemotherapy but now disease is progressing
MSI negative
Wants to live 6 more months to the wedding of his granddaughter

13. Evaluation of response to treatment
Metastatic disease
Adjuvant Treatment
Neoadjuvant treatment

14. Evaluation of response: Metastatic disease
Measurable disease
non-measurable disease
Change in size (RECIST)
Vitality
New lesions
Time to progression
Survival
CTC
Liquid Biopsy
Disappearance
Vitality
New lesions
Time to progression
Survival
CTC
Liquid biopsy

15. Evaluation of response: adjuvant and neoadjuvant
Change in size
Vitality
Disease free survival
Survival
Disease free survival
Survival

16. Conclusions
Treatment related decisions include assessment of patient’s condition and goals, stage of diseases, sensitivity to treatment and treatment toxicity
Assessment of response in the presence of measurable disease involves: size, tumor vitality, time to progression and survival
Assessment of response in the adjuvant setting includes disease free survival and overall survival