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Oncology

Cancer Principles and Overview

General overview of cancer (unregulated cell growth forming benign or malignant tumours), risk factors, common warning signs, prevention strategies, and the importance of early detection and referral in the Ugandan context. Covers common cancers and groups at increased risk.

Also known as: Oncology Basics, Cancer Warning Signs

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Referral and warning signs

When to refer

Urgent referral to HC4/Hospital/Cancer Centre needed for patients with URGENT signs/symptoms suggestive of malignancy. Refer ALL patients with suspected cancer based on persistent warning signs or abnormal screening results for diagnostic workup and management.

Red flags

  • See 'Urgent Signs and Symptoms' list in signs_symptoms field.
  • Any unexplained persistent symptom from the 'Early Warning Signs' list, especially if >2 weeks.

Signs and symptoms

  • General Early Warning Signs (>2 weeks duration): Sudden unexplained weight loss, Painless or painful swelling/lump/thickening, Sores that fail to heal, Hoarseness or persistent cough, Abnormal bleeding or discharge (vaginal, rectal, nipple, urinary), Persistent indigestion or difficulty swallowing (dysphagia), Change in normal bowel or bladder habits, Chronic non-healing ulcers, Chronic persistent pain, Change in a skin wart or mole.
  • Urgent Referral Signs/Symptoms (Examples): Haematological (Neutropenia, anaemia, bleeding, hyperviscosity, high leucocytosis >50x10^9/L), Lung (Haemoptysis, Superior Vena Cava obstruction), Upper GI (Chronic GI bleeding, dysphagia, persistent vomiting, weight loss, abdominal mass, obstructive jaundice), Lower GI (Rectal bleeding with change in bowel habit, palpable rectal mass, iron deficiency anaemia), Breast (Discrete hard fixed lump, skin/nipple changes - eczema/retraction/peau d'orange, bloody nipple discharge), Gynaecological (Postmenopausal bleeding, persistent intermenstrual bleeding, vulval lump/bleeding), Urological (Hard irregular prostate, macroscopic haematuria, testicular mass, abdominal mass in urinary tract), CNS (Progressive neurological deficit, new onset seizures, headaches, mental changes, signs of raised intracranial pressure).

Risk factors

  • Special Groups at Increased Risk: HIV-positive patients, Persons with Albinism, Older age (>65 years), Women (for breast/cervical cancer).
  • General Risk Factors: Smoking/Tobacco Use (Lung, Oesophagus, Larynx, Mouth, Kidney, Bladder, Pancreas, Stomach, Cervix), Unhealthy Diet (Low fibre, high fat/sugar, processed/charred food), Overweight and Obesity (Oesophagus, Colorectal, Breast, Endometrium, Kidney), Physical inactivity, Excessive Alcohol Use (Oral cavity, Oesophagus, Larynx, Liver, Colorectal, Breast), Environmental Pollution / Occupational Exposure (Aflatoxins, asbestos, fumes, radiation), Oncogenic Infections (HPV - Cervical/Oral/Anal; HBV/HCV - Liver; H. pylori - Stomach; HIV - KS/Lymphoma/Cervical; Schistosomiasis - Bladder; Liver Fluke - Cholangiocarcinoma), Radiation Exposure (UV - skin; Ionizing - leukaemia/solid tumours).

Diagnosis

Clinical assessment

Suspicion raised by persistent warning signs/symptoms (>2 weeks) or presence of urgent signs. Requires thorough history (including risk factors) and physical examination. Early diagnosis in symptomatic populations is crucial.

Investigations

  • Investigations depend on suspected cancer type (see individual entries).
  • Biopsy (FNA, core needle, incisional, excisional) is usually required for definitive histological diagnosis.
  • Imaging (Ultrasound, X-ray, CT, MRI, Endoscopy) used for locating tumour, staging, guiding biopsy.
  • Blood tests (CBC, LFTs, RFTs, tumour markers - e.g., PSA, AFP, LDH) may be supportive.

Diagnostic criteria

Requires histological confirmation via biopsy in most cases.

Management

Non-pharmacological management

  • Referral to specialized cancer treatment centre (e.g., Uganda Cancer Institute - UCI, Regional Referral Hospitals with oncology services) for diagnosis confirmation, staging, and multidisciplinary management planning.
  • Management depends heavily on cancer type, stage, and patient factors.
  • Includes options like surgery, radiotherapy, palliative care.
  • Psychosocial support.

Pharmacological treatment

  • Specific chemotherapy, hormonal therapy, targeted therapy, immunotherapy regimens determined by specialists based on cancer type/stage/biomarkers.
  • Supportive medications (analgesics, antiemetics, G-CSF, etc.).

Monitoring

Requires specialist monitoring during and after treatment for response, recurrence, and side effects.

Complications

  • Metastasis (spread to other organs)
  • Organ failure
  • Pain
  • Malnutrition / Cachexia
  • Infections
  • Bleeding / Anaemia
  • Thromboembolism
  • Paraneoplastic syndromes
  • Treatment-related side effects
  • Psychological distress

Prevention

  • Primary Prevention: Risk Factor Reduction (Tobacco cessation, healthy diet, maintain healthy weight, physical activity, limit alcohol, reduce environmental/occupational exposures), Infection Control/Treatment (HBV vaccination, HPV vaccination - girls age 10, Safe sex practices, Treatment of HIV/HCV/H.pylori/Schistosomiasis), Sun protection (especially for Persons with Albinism).
  • Secondary Prevention (Screening/Early Detection): Breast Cancer (Breast Self-Examination - BSE awareness, Clinical Breast Examination - CBE, Mammography - referral level), Cervical Cancer (Visual Inspection with Acetic Acid - VIA or Lugol's Iodine - VILI - screen & treat approach possible at lower levels, Pap Smear - cytology, HPV DNA testing - emerging standard), Prostate Cancer (Screening controversial, involves PSA +/- DRE - discussion with patient), Colorectal Cancer (Screening options include FOBT/FIT, Sigmoidoscopy, Colonoscopy - referral level).

Patient education

  • Importance of recognizing cancer warning signs and seeking care early.
  • Lifestyle modifications for primary prevention (diet, exercise, smoking/alcohol avoidance).
  • Importance of vaccinations (HBV, HPV).
  • Availability and importance of screening tests (Cervical, Breast).
  • Need for referral for diagnosis and specialized treatment.
  • Address myths and misconceptions about cancer.

Uganda-specific notes

High burden of infection-related cancers (Cervical, Liver, Kaposi Sarcoma, Burkitt's). Late presentation is common. Access to diagnostics (biopsy, imaging, pathology) and treatment (surgery, radiotherapy, chemotherapy) is concentrated at UCI and some RRHs. Screening programs (VIA for cervical) are crucial. Palliative care important.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 12, Sections 12.1, 12.2

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