[L. cancer, crab, suppurating ulcer]
Malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of healthy tissues locally or throughout the body. Cancer is the second leading cause of death in the U.S. after cardiovascular disease. In 2013, the NCI estimated that more than 1,660,000 Americans would be diagnosed with cancer and that approx. 580,000 would die as a result. The most common cancers in the U.S. are lung, breast, colon, prostate, and skin. Because most cancers occur in patients who are 65 or older, the incidence of cancer is expected to increase as the population ages. More than 200 kinds of cancer have been identified. Cancers that arise from epithelial tissues are called carcinomas; from mesenchymal tissues, sarcomas; from glial cells, gliomas; from lymphatic cells, lymphomas; from blood-forming cells, leukemias; from pigmented skin cells, melanomas; and, from plasma cells, myelomas.
SYN: SEE: malignancy (2)
SEE: carcinoma; SEE: leukemia; SEE: lymphoma; SEE: oncogene; SEE: sarcoma
Cancer cells have several reproductive advantages over normal cells. They can make proteins that stimulate their own growth or new blood vessels to bring them nourishment. They can produce enzymes that prevent their chromosomes from aging. They can invade the lymphatic system and bloodstream and find places to metastasize.
Usually, as cancer cells proliferate, they become increasingly abnormal and require more of the body's metabolic output for their growth and development. Damage caused by their invasion of healthy tissues results in organ malfunction, pain, and, often, death. SEE TABLE: Estimated Number* of New Cancer Cases and Deaths by Sex, U.S., 2013*
Ionizing radiation, ultraviolet light, some viruses, and drugs that damage nucleic acids may initiate the genetic lesions that result in cancers. The best-known and most widespread type of carcinogen exposure, however, is consumption of tobacco. The ACS estimates that one third of the cancer deaths that occur annually in the U.S. are related to nutrition and other lifestyle factors. Some cancers are familial, i.e., genetic; others result from occupational exposures to carcinogens. Ironically, chemotherapeutic drugs used to treat some cancers may damage chromosomes and occasionally cause secondary malignancies.
Symptoms of widespread cancer include pain, malnutrition, weakness, fatigue, bone fractures, and strokelike syndromes. Early warning signs of cancer may be remembered by the mnemonic CAUTION: Change in bowel or bladder habit; A sore that does not heal; Unusual bleeding or discharge; Thickening or mass in the breast or other body parts; Indigestion or difficulty in swallowing; Obvious change in a wart or a mole; Nagging cough or hoarseness. People should seek prompt medical attention if they observe any of these signs.
The location of a suspected lesion often dictates the means to diagnose cancer: men with urinary symptoms may be screened for prostate cancer with a prostate specific antigen (PSA) test; an alpha-fetoprotein (AFP) test may be used to screen for liver cancer. Several other tumor markers (such as the CA 125 test for ovarian cancer) are used only after a diagnosis has already been made. Endoscopy and radiography are typically used to locate and assess the extent of the disease, but definitive diagnosis still rests on the examination of cytological specimens (such as the Papanicolaou [Pap] test) or the pathological review of biopsy specimens.
CANCER (A) Ovarian carcinoma cells and (B) adenocarcinoma of the prostate (orig. mag. ×500); SEE TABLE: Controversies in Cancer Screening in the General Population*
Screening for cancers can identify some malignancies before they have invaded neighboring tissues or become widespread. The most widely used screening tests include the Pap test for cervical cancer, mammography for breast cancer, PSA tests for prostate carcinoma, and occult blood tests and colonoscopy for intestinal cancers.
Surgery, chemotherapy, immunotherapy, hormone therapy, radiation therapy, and combined-modality therapies often are effective methods for treating patients with cancer. The specific treatment used depends on the type, stage, and location of the cancer and the patient's general health.
The pain associated with cancer is often severe. Cancer patients may suffer depression and anxiety and have nutritional deficits. Guidelines addressing these issues are readily available, e.g., from the U.S. Department of Health and Human Services' Agency for Health Care Policy and Research. Publications may be obtained by calling 1-800-4-CANCER or from websites such as from the ACS (www.cancer.org).
There must be close collaboration among the entire health care team and the patient and family must be encouraged to participate in care. The patient's knowledge of the disease is determined, misinformation is corrected, and information is supplied about the disease, its progression, its treatment, and expected outcome. Such information should be updated regularly. The patient's and family's coping mechanisms are supported, and verbalization of feelings and fears, esp. with changes in body image, pain and suffering, and feelings about dying and death, is encouraged. Participation in local support groups is encouraged for both patients and families.
Assistance is provided with personal hygiene and physical care as needed. Physical care is directed at the maintenance of fluid and electrolyte balance and proper nutrition. Nutrition is a special concern because tumors compete with normal tissues for nutrients and grow at their expense and because the disease or treatments can cause anorexia, altered taste sensations, mouth ulcerations, vomiting, diarrhea, and draining fistulas. Nutritional support includes assessing the patient's status and problems, experimenting to find foods that the patient can tolerate, avoiding highly aromatic foods, and offering frequent small meals of high-calorie, high-nutrient soft foods along with fluids to limit fatigue and to encourage overall intake. Intake of noncaffeinated liquids should be encouraged: 2 quarts per day of juices or other caloric beverages in frequent, small amounts rather than water alone. Elimination is maintained by administering stool softeners as necessary if analgesic drugs result in constipation.
Using careful and gentle handling, the health care professional assists with range-of-motion exercises, encourages ambulation and mobility, and turns and repositions the immobile patient frequently to decrease the deleterious multisystemic effects of immobilization. The patient is made comfortable by correct body alignment, noninvasive measures (such as guided imagery and cutaneous stimulation), and medication (preferably administered on a regular schedule to prevent pain, with additional dosing to relieve breakthrough pain). Emotional assistance includes allaying the patient's fears of helplessness and loss of control; providing hope for remission or long-term survival but avoiding giving false hope; and providing the patient with realistic reassurance about pain control, comfort, and rest. Psychological counseling and antidepressant therapies may be helpful.
Hospice care (at home or in a dedicated center), if needed, is discussed with the patient and family. The goal is to provide good quality of life with minimal discomfort, pain, and restrictions rather than to continue specific therapy. Family members are encouraged to assume an active role in caring for the patient. Communication is fostered between patient and family and other health care providers, and the patient is helped to maintain control and to carry out realistic decisions about issues of life and death.
To provide effective emotional support to the patient and family, health care professionals must understand and cope with their own feelings about terminal illness and death and seek assistance with grieving and in developing a personal philosophy about dying and death. They will then be better able to listen sensitively to patients' concerns, to offer genuine understanding and comfort, and to help patients and family work through their grief.
SEE: Nursing Diagnoses Appendix
Carcinoma of the uterine cervix, Kaposi sarcoma, or non-Hodgkin lymphoma.
A malignancy that arises in the cells of the urinary bladder. In Western nations, most of the cases are transitional cell carcinomas. Common causes include cigarette smoking, occupational exposure to carcinogens, or chronic bladder infection. Symptoms of bladder cancer may include painful urination, bloody urination, or frequent or urgent urination. Depending on the extent of invasion or spread of the tumor, it may be treated with endoscopy, surgery, chemotherapy, or immunotherapy.
In 2013 the NCI estimated that approx. 72,500 people would be diagnosed with bladder cancer and that more than 15,000 would die of the disease.
Patients who have been treated for bladder cancer can be monitored for recurrence of the disease by evaluating their urine for the presence of chromosomes 3, 7, 9p21, and 17, or for fibrin and fibrinogen.
Any malignancy of bone tissue. Primary bone tumors (such as osteosarcomas) are rare in adults; they are seen more often in children and adolescents. Secondary or metastatic bone tumors are far more common. Tumors arising in other areas of the body that metastasize to the bones most often spread from organs such as the prostate or the breast.
SEE: breast cancer
A malignant neoplasm of the cervix of the uterus.
With an incidence of 15:100,000, it is the third most common cancer of the female reproductive tract in the U.S. and causes 5% of all cancer deaths among women. Worldwide, it is the second most common cause of death resulting from cancer. Although it may occur in younger women, the average age at diagnosis is 54. The disease is insidious, asymptomatic in the early stages, and best treated when recognized at an early stage.
Some strains of the human papillomavirus (HPV) are carcinogenic to the cervical epithelium. While there are other risk factors (such as tobacco smoking, early age at first intercourse, and having multiple sex partners), HPV infection is the major factor responsible for the development of this cancer.
Periodic Pap tests are recommended for all sexually active women. The frequency of testing depends on the woman's age and whether she has had abnormal or previously normal results. The tests identify cellular changes with 95% accuracy. Dilatation and curettage, punch biopsy, and colposcopy may be done if Pap test findings raise the suspicion of cancer. If abnormal cells are detected, HPV testing is often performed to screen for the presence of one of the high risk types of the virus.
SEE: Bethesda System, The; SEE: cervical intraepithelial neoplasia; SEE: colposcopy; SEE: cryosurgery; SEE: loop electrode excision procedure; SEE: Papanicolaou test
Management varies from cryotherapy or laser therapy for low-grade squamous intraepithelial lesions, conization for carcinoma in situ, to hysterectomy for preinvasive cervical cancer in women who are not planning to have children. Stage-related management of invasive cervical carcinoma includes radiation and/or hysterectomy.
Vaccination against human papillomavirus virus (HPV).
SEE: HPV vaccine.
The availability of adolescent HPV vaccination programs should be discussed with teens and their parents. Sexually active young women should be educated about safe sexual practices (including abstinence and contraception) and should be encouraged to participate in periodic cervical cancer screening during routine well-woman examinations. Health care agencies should develop and use techniques to ensure that test results are effectively communicated to screened patients. Referral of patients for treatment of confirmed cervical cancer should include multidisciplinary support of the patient by women's health advocates, nurses, social workers, and oncologists.
Cancer of the skin of the scrotum due to chronic irritation from coal soot.
ABBR: CRC A malignancy of the colon or rectum.
CRC is the second leading cause of cancer deaths in the U.S. At some time during their lives, approx. 5% of Americans will be diagnosed with the disease. In 2013 the ACS estimated that approx. 102,000 Americans would be newly diagnosed with colorectal cancer and that it would cause more than 40,000 deaths.
The cancer occurs more often in people with a family history of the disease, those with familial adenomatous polyposis, and in those with inflammatory bowel diseases such as ulcerative colitis. It is also found more often in the obese and in those who consume a high-fat, low-fiber diet.
Symptoms may be absent or may include change in the usual pattern of bowel habits, esp. in those over 40; recent onset of constipation, diarrhea, or tenesmus in an older patient; and bright red or dark blood in the stool. Laboratory findings may include iron-deficiency anemia or positive fecal occult blood tests.
Diagnosis may be suggested by findings on digital rectal examination, anoscopy, flexible or rigid sigmoidoscopy, colonoscopy, virtual colonoscopy, or barium enema examination. It is confirmed by biopsy of suspicious lesions. When colorectal carcinoma is diagnosed, additional tests are conducted to determine the stage of the disease (chest radiographs, CT, MRI, and blood studies, including carcinoembryonic antigen levels, and liver function studies). Carcinoembryonic antigen is helpful in monitoring patients during and following treatment to determine effectiveness and detect recurrence or metastasis.
Most cases of colorectal cancer cannot be prevented. However, screening of asymptomatic men and women of average risk starting at age 50, with tools such as annual fecal occult blood testing (over a 3-day period), sigmoidoscopy, or colonoscopy can sometimes detect the disease in its early stages. During colonoscopy, removal of benign polyps prevents their progression to malignant tumors. If polyps are found, colonoscopy should be repeated in 3 to 5 years (depending on the presence of other risk factors). Neither digital rectal examination nor testing of a single stool specimen from the digital examination provides adequate screening. Patients at increased risk for colorectal cancer (those who have had previous colorectal adenomas or resected cancers or a history of ulcerative colitis or of colon cancer in a first-degree relative younger than 60) should undergo screening more frequently and at an earlier age.
Surgical resection performed by laparotomy, minimally invasive surgery, microsurgery, or laparoscopy can cure localized colorectal cancer. Whatever procedure is used, the type of surgery depends on the location of the tumor, and the goal of the surgery is removal of the malignant tumor and adjacent tissue and any lymph nodes that may contain cancer cells. Adjuvant therapies may include chemoembolization of blood vessels that feed the primary tumor or metastases; radiation therapy; brachytherapy; chemotherapy; or monoclonal antibody therapy.
After diagnosis, treatment with aspirin appears to reduce both the likelihood of disease progression and mortality. Among effective chemotherapeutic agents introduced into practice since 2000, oxalitplatin appears to be the most effective.
Health care providers should teach patients the importance of colorectal screening and indicate applicable lifestyle modifications (a low-fat diet, maintenance of a normal body mass index). Patients with familial colon cancer syndromes, such as familial adenomatous polyposis, should be counseled about the need for close surveillance by a gastroenterologist.
Aspirin and other nonsteroidal anti-inflammatory drugs appear to reduce the number of colon polyps, thus decreasing the risk of developing colorectal cancer. Patients interested in such therapy should discuss its potential risks and benefits with their health care providers.
Patients diagnosed with colorectal cancer who undergo surgery need counseling about the operation, the duration of recovery, and, in many cases, the use of a postoperative colostomy. Before surgery, a stomal therapist consults with the surgeon regarding appropriate stoma location, and the abdomen is marked. The therapist answers questions from the patient and family and begins to develop a relationship that will support the patient through postoperative care and teaching. Patient and family are encouraged to access the ACS (800-ACS-2345 or www.cancer.org) for additional information.
SYN: SEE: carcinoma of the colon; SEE: colorectal carcinoma
Cancer that develops in the lining of the uterus. It most often arises in cells that produce mucin, and most endometrial cancers are therefore adenocarcinomas.
Most endometrial cancers are found in women over the age of 60.
Risk factors for the development of endometrial cancer include never having been pregnant, early age at first menstruation, late menopause, exposure to estrogens or tamoxifen, obesity, polycystic ovarian syndrome, or a family history of hereditary colon cancer.
SYMPTOMS AND SIGNS
Common symptoms include vaginal spotting.
Endometrial cancer is diagnosed by speculum examination of the reproductive organs, pelvic imaging, and curettage of cells from the inside of the uterus.
The risk of developing endometrial cancer is reduced in women who exercise regularly and in those who use oral contraceptives that combine estrogen and progesterone.
Hysterectomy (surgical removal of the uterus), chemotherapy, and radiation therapies are commonly employed, depending on whether the disease is limited to the uterine lining or whether it has spread more extensively in the pelvis.
In the U.S. in 2013, the NCI estimated that 49,500 women would be newly diagnosed with endometrial cancers and that approx. 8200 would die of the disease.
SEE: ovarian cancer
SEE: esophageal cancer
A malignancy that begins to grow in the cells that form the inner surfaces of the fallopian tubes, usually an adenocarcinoma. It is the least common form of gynecological cancer.
ABBR: FMTC A rare, autosomal, dominantly inherited predisposition to medullary carcinoma of the thyroid. The disease is genetically related to the multiple endocrine neoplasia (MEN) syndromes. However, families affected by FMTC rarely develop hyperparathyroid tumors or pheochromocytoma.
Adenocarcinoma of the stomach. About 50% to 60% of all carcinomas of the stomach occur in the pyloric region. About 20% occur along the lesser curvature; the rest are located in the fundus, particularly along the greater curvature. Although this form of cancer is common throughout the world in people of all races, the incidence of gastric cancer exhibits unexplained geographic, cultural, and gender differences, with the highest incidence in men over 40 and higher mortality in China, Korea, Japan, Taiwan, Iceland, Chile, and Austria.
From 1930 to the 1990s, the incidence of gastric cancer declined from about 38 cases per 100,000 to about 6 cases per 100,000. In 2013 the NCI estimated there would be 21,600 new cases of gastric cancer in the U.S. and approx. 11,000 deaths from this disease. Worldwide, nearly one million patients with gastric cancer come to medical attention each year.
More than 75% of gastric cancers are linked to chronic infection of the gastric mucosa by the bacterium Helicobacter pylori. Other suggested causes include a diet rich in pickled or smoked foods, familial inheritance, and a history of gastric surgery.
Malnutrition occurs as a result of impaired eating, the metabolic demands of the growing tumor, or obstruction of the GI tract. Iron-deficiency anemia results as the tumor causes ulceration and bleeding. The tumor can interfere with the production of the intrinsic factor needed for vitamin B12 absorption, resulting in pernicious anemia. As the cancer spreads to regional lymph nodes and nearby structures and metastasizes to other structures, related complications occur.
SYMPTOMS AND SIGNS
In the early stages, the patient may occasionally experience pain in the back or in the epigastric or retrosternal areas that is relieved by nonprescription analgesics. As the tumor grows, the patient may notice a vague feeling of fullness, heaviness, and abdominal distention after meals. Depending on the progression of the cancer, the patient may report weight loss due to disturbance of the appetite, nausea; and vomiting. There may be dysphagia and coffee-ground vomitus, if the tumor is located in the cardia and slowly bleeds. Weakness and fatigue are common. Because early symptoms include chronic dyspepsia and epigastric discomfort, patients may self-treat with over-the-counter antacids or histamine blockers, delaying prescribed therapies and allowing the cancer to progress.
Palpation of the abdomen may disclose a mass. A skilled examiner may be able to palpate enlarged lymph nodes, esp. in the supraclavicular and axillary regions.
Gastric cancer is diagnosed by fiber-optic endoscopy with biopsy. Studies to rule out specific organ metastases include endoscopic ultrasonography, CT scans, chest radiographs, liver and bone scans, and liver biopsy.
Radical surgery to remove the tumor is possible in more than one third of patients. Even in the patient whose disease is not considered surgically curable, resection may temporarily ease symptoms and improve the patient’s response to chemotherapy and radiation therapy. The nature and extent of the lesion determine the type of surgery. Surgical procedures include gastroduodenostomy, gastrojejunostomy, partial gastric resection, and total gastrectomy. If metastasis has occurred, the omentum and spleen may have to be removed.
Chemotherapy for GI tumors may help control symptoms and signs and prolong survival. Gastric adenocarcinomas respond to several agents, including fluorouracil, carmustine, doxorubicin, and mitomycin. Tumors that express HER2 antigens respond to treatment with trastuzumab (a monoclonal antibody that targets the human epidermal growth factor). Antispasmodics, antacids, and proton pump inhibitors may help relieve GI acidity and reflux symptoms. Antiemetics can control nausea, which intensifies as the tumor grows. Analgesics, sedatives, and tranquilizers are used to control pain and anxiety.
IMPACT ON HEALTH
The prognosis for a particular patient depends on the stage of the disease at the time of diagnosis, but overall the 5-year survival rate is about 19%.
Nutritional intake is monitored, and the patient is weighed periodically. The health care provider initiates comprehensive clinical and laboratory investigations, including serial studies as indicated, if these have not already been done. The patient is prepared physically and emotionally for surgery, chemotherapy, or radiotherapy. During hospitalization, all general patient care concerns apply.
Throughout the course of the illness, a high-protein, high-calorie diet with vitamin supplementation helps the patient avoid or recover from weight loss, malnutrition, and anemia and promotes wound healing. Frequent small meals are offered.
To stimulate a poor appetite, antidepressant or steroid drugs may be administered. The patient is instructed in use of all drugs and the expected adverse effects of treatment, as well as in management strategies for these effects.
Radiation therapy may cause nausea, vomiting, local skin damage, malaise, diarrhea, and fatigue. Chemotherapy may cause bone marrow suppression, infection, nausea, vomiting, mouth ulcers, and hair loss. During radiation or chemotherapy, oral intake is encouraged to remove toxic metabolites. Bland fruit juices, ginger ale, or other fluids and prescribed antiemetics are provided to minimize nausea and vomiting; comfort and reassurance are offered as needed. The patient is advised to report persistent adverse reactions.
The patient is encouraged to follow a normal routine as much as possible after recovery from surgery and during radiation therapy and chemotherapy. He or she should stop activities that cause excessive fatigue (at least temporarily) and incorporate rest periods. The patient should avoid crowds and people with known infections. Home-health care is provided as necessary. If curative treatment fails, palliative care and psychological support continues, with questions answered honestly but tactfully. Home or in-patient hospice care referrals are suggested as available.
SYN: SEE: stomach cancer
Squamous cell carcinoma usually arising in the pharynx, oral cavity, or larynx. Research has shown links between human papillomavirus infection, tobacco smoking, and excessive alcohol use and head and neck cancers.
SEE: Lynch syndrome.
A cancer whose presence is diagnosed in the time between scheduled screening tests, e.g., a breast cancer that is not detected by regular periodic mammography, professional examination, or self-breast exams.
A cancer that grows slowly and has no important health effect on the patient.
A squamous cell carcinoma of the lower lip, usually seen in men or smokers.
Malignancy of the liver that results either from spread from a primary source or from a primary tumor of the liver itself. The former is the more frequent cause. The liver is the most common site of metastatic spread of tumors that disseminate through the bloodstream. The prognosis for survival is from a few months to 1 yr.
In the U.S. for 2013, the NCI estimated that more than 30,600 people would be diagnosed with liver cancers and that nearly 21,700 would die of the disease.
Male sex, hepatitis B or C, cirrhosis, and other liver diseases are predisposing factors.
SYMPTOMS AND SIGNS
The disease may cause severe pain and tenderness, cachexia (loss of weight), and encephalopathy. Jaundice is common. The liver is enlarged, its surface is nodular, and a central depression or umbilications can often be detected.
Liver cancer may be diagnosed by ultrasound and by an alpha-fetoprotein (AFP) blood test.
Depending on the severity, treatment may include surgery, radiation therapy, targeted therapy, chemotherapy, and other local treatments (ablation or embolization).
The patient should be monitored for nutritional deficiencies, bleeding, changes in mental status, skin breakdown, impaired airway, and infection.
The deadliest form of cancer in the U.S., involving cells that originate in the bronchi or lung. The term includes four cell types: squamous cell (epidermoid) carcinoma, adenocarcinoma, large cell (anaplastic) cancer, and small cell (oat cell) cancer.
SYN: SEE: bronchogenic carcinoma
LUNG CANCER Lung cancer seen endoscopically. The tumor is bleeding after being biopsied.
In 2013, the NCI estimated that more than 228,000 people would be diagnosed with lung cancer and that about 159,500 would die of the disease. It is the second most common cancer in both men and women.
The vast majority are caused by carcinogens in tobacco smoke, including secondhand smoke. Other risks include exposure to carcinogenic industrial and air pollutants (asbestos, uranium, arsenic, nickel, chromium, iron oxides, coal dust, and radioactive dusts), concentrations of radon gas, and familial susceptibility.
SYMPTOMS AND SIGNS
Symptoms may include persistent cough, chest pain, dyspnea, weight loss, or hemoptysis. Changes in normal respiratory patterns or hoarseness, as well as pneumonia, bronchitis, epigastric pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body are other possible signs.
Diagnostic tests include a chest x-ray, CT scan, cytological sputum analysis, and bronchoscopy. Other tests include needle biopsy, magnetic resonance imaging, thoracentesis, thoracotomy, mediastinoscopy, or pulmonary function tests.
Treatment includes lung surgery, radiation therapy, and chemotherapy (including epidermal growth factor receptor blockers) often provided serially or in combination.
People with localized lung cancer have an approx. 5-year survival of 50%. People with widely metastatic lung cancer have a 5-year survival of less than 5%.
Staging determines the extent of the disease and aids in planning treatment and predicting the prognosis. Lung cancer is relatively difficult to cure but much easier to prevent. Children and adolescents should be discouraged from smoking tobacco products, and current smokers should be assisted in their efforts to quit, e.g., through referrals to local branches of the ACS, smoking-cessation programs, individual counseling, or group therapy.
SCREENING AND PUBLIC HEALTH
Chest x-rays do not show small, early cancers, but CT scanning can be used to screen people who have a long history of smoking and evidence of emphysema. In this high-risk group, screening detects the disease in its early stages when it is most likely to be curable. Smokers over the age of 55 who undergo annual lung cancer screening with low-dose CT scans have improved survival relative to those who do not. However, the public health costs of mass screening are high compared with the cost of encouraging smokers to quit or teaching teenagers not to start smoking.
Squamous cell carcinoma of the mouth or tongue. Oral cavity cancers are only rarely caused by salivary gland tumors or sarcomas.
In 2013 the NCI estimated that in the U.S. around 36,000 people would be diagnosed with oral cancers and that nearly 6,850 would die of the disease.
Any malignant growth in an ovary or invading the surrounding peritoneum.
Currently, more women die of epithelial ovarian cancer than of all other gynecological cancers combined. A small percentage of patients with ovarian cancer may have a hereditary predisposition, e.g., they have breast cancer type 1 (BRCA-1) or breast cancer type 2 (BRCA-2) genes. High-risk women include those with multiple first-degree relatives (mother, sister, daughter) or second-degree relatives (aunt, grandmother, cousin) with histories of breast or ovarian cancer. Preventive surgery to remove the ovaries and fallopian tubes is the only way such women can significantly reduce their risk.
The NCI estimates that about 22,240 American women will be diagnosed with ovarian cancer in 2013 and that around 14,000 will die of the disease. Between 1% and 2% of women born today will be diagnosed with ovarian cancer sometime during their lives. The incidence rates are higher in women of European-American ancestry than in other ethnic groups. Most cases (70%) are diagnosed when the disease is already at an advanced stage because early detection methods are still unsatisfactory.
SYMPTOMS AND SIGNS
The symptoms of ovarian cancer are often nonspecific and often mimic those of irritable bowel (constipation, vague abdominal pain, bloating). Initial laboratory studies (routine blood tests and x-rays) are often unremarkable.
Diagnostic tests include an annual pelvic exam (the presence of atypical squamous cells of uncertain significance [ASCUS] or abnormal results); rectovaginal exam (for ovarian enlargement); or transvaginal ultrasound with Doppler.
Attempts to improve early detection of ovarian cancer (similar to biomarkers like cancer antigen 125 [CA-125] and radiologic studies like transvaginal ultrasound) have not been shown to improve early diagnosis or survival from the disease. Early screening unfortunately increases the rate of false-positive findings, which in turn increases the rate of complications from unnecessary laparoscopy or surgery.
SEE: Patient Care, below.
The probability of surviving ovarian cancer depends on the stage at which the disease is detected. Stage 1 disease (in which the cancer is still confined to the ovary itself) has a 5-year survival rate of greater than 90%. Disease that has spread within the peritoneum or widely metastasized has a 5-year survival rate of a little better than 25%.
Ovarian cancer patients may feel threatened or vulnerable. They benefit from pretreatment support and education. Health care professionals address the patient's psychosocial needs while preparing her for treatment and manage the potential adverse reactions and the treatment and changes related to advancing disease.
The first step in care is typically surgical debulking of the tumor. In this phase the surgical oncologist attempts to remove not only the primary tumor, but also as many small tumorlets as can be found within the peritoneum. The patient and family should be taught about the extensive surgical procedure and what to expect after surgery. After surgery, the patient is monitored for infection, circulatory complications, fluid and electrolyte imbalances, and pain. The patient who is to receive chemotherapy should be taught about major adverse reactions to the usual medications employed: taxanes and platinum-based drugs cause fatigue, nausea and vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, difficulty concentrating (chemo brain), and myelosuppression. The patient is also taught the measures to prevent and manage these problems. Chemotherapy may be given directly into the peritoneum or intravenously. Depression, anger, frustration, and anxiety are common side effects.
After the acute phase of treatment, the patient may undergo premature menopause; loss of fertility; alterations in body image, sexual function, and family relationships; impaired functional capacity; financial difficulties; and loss of spiritual well-being. The patient should be assessed for mood changes, inability to concentrate, fatigue, insomnia, and other symptoms of depression. Her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history should be reviewed for factors that contribute to depression. Participating in a support group, meeting with mental health professionals, and taking an antidepressant or antianxiety medication can help alleviate depression and anxiety.
Advancing or relapsing ovarian cancer may cause complications, including development of ascites, intestinal obstruction, deep vein thrombosis, malnutrition and cachexia, lymphedema, and pleural effusion. Current 5-year survival rates for ovarian cancer are about 30% to 40%. If ovarian cancer recurs after treatment or fails to regress with treatment, palliative and end-of-life care may aid both patients and their families.
SEE: Pancreatic cancer.
Carcinoma of the pancreas. Although the causes of pancreatic cancer are unknown, it has been found in more men than women, more blacks than whites, more smokers than nonsmokers, and more patients with a history of chronic pancreatitis and diabetes mellitus. When cancer occurs in the head of the pancreas, where it may obstruct the bile ducts and cause jaundice, the disease is most likely to be diagnosed at an early stage, when it may be most responsive to therapy. Surgical excision of the tumor and treatment with chemotherapy or radiotherapy may prolong survival in some patients. Only 4% of victims of pancreatic cancer survive 5 years.
SYN: SEE: carcinoma of the pancreas; SEE: cancer of the pancreas; SEE: pancreatic carcinoma
In 2013, the NCI estimated that more than 45,200 people in the U.S. would be newly diagnosed with pancreatic cancer and that approx. 38,500 would die of the disease. Between 1% and 2% of children born today will be diagnosed with pancreatic cancer during their lives. The disease rarely occurs in people under 40 and is most often diagnosed at around age 70.
Although the causes of pancreatic cancer are unknown, many people have a familial or genetic predisposition to the disease.
SYMPTOMS AND SIGNS
Small pancreatic cancers usually cause no symptoms, and, as a result, patients typically experience no problems until the disease has established itself, often after more than a decade, and has invaded neighboring organs or spread widely to other regions of the body. Symptoms, when they do occur, include anorexia, weight loss, abdominal pain, back pain, nausea, vomiting, or jaundice.
The tumor is first identified with abdominal ultrasonography or CT and then is pathologically proven by microscopic examination of a biopsy specimen.
Effective screening programs for the early detection of pancreatic cancer do not exist, but active research on serum biomarkers and radiological studies, and how best to deploy them are topics of active research. Most approaches aim to identify plasma biomarkers, such as proteins specific to pancreatic cancer in people who may be at highest risk for the disease, i.e., those who have several family members with pancreatic cancer or hereditary pancreatitis. These approaches are still experimental, not proven.
Combination chemotherapies used to treat pancreatic cancer include gemcitabine, paclitaxel, and FOLFIRINOX. Toxicities that limit the dose of chemotherapy that patients can tolerate include neutropenia and sepsis. When a tumor is limited to the head of the pancreas, it may be surgically removed.
People with localized disease have a little less than a 25% 5-year survival rate. Surgical removal of a localized tumor can cure the disease; however, 80% of all patients are detected after the cancer has already spread far enough to prevent surgical resection. People with distant metastases at the time of diagnosis have a 5-year survival rate of less than 2%.
Like many of the deadliest forms of cancer, pancreatic adenocarcinoma causes significant emotional distress for patients and the people who care for them. Oncology nurses and physician specialists provide much of the patient education and reinforcement, as well as the psychosocial support needed by patients and families. Attentiveness to patient concerns about treatment, prognosis, and pain and symptom management can alleviate worry and enhance effective adaptation to the illness and its treatment. In patients in whom disease is incurable at the time of diagnosis, involvement of palliative care specialists, support groups, and hospice can improve quality of life.
The original cell or tissue type from which a metastatic cancer arises.
SEE: prostate cancer
SEE: Hard cancer.
A mass that appears in the body having the same cell type and/or genetic signature as a cancer previously found in the patient; metastasis.
The appearance of a new tumor in a cancer survivor and originating in a different cell type than the primary tumor, e.g., of a kidney cancer in a patient with a history of thyroid cancer, or a colon cancer in a patient with a history of lymphoma.
A broad term that includes basal cell carcinomas, squamous cell carcinomas, and melanomas. Together, these skin cancers are the most common cancers in the U.S. They are all associated with excessive exposure to ultraviolet light, e.g., sun exposure.
SEE: basal cell carcinoma; SEE: squamous cell carcinoma; SEE: melanoma
According to the U.S. Preventative Services Task Force (USPSTF), benefits from routine screening for skin cancers with a total body skin examination are unproven, even in high-risk patients.
SEE: Gastric cancer.
Widespread or advanced cancer, from which recovery is not expected.
Any of a group of testicular cancers that include choriocarcinomas, embryonal carcinomas, seminomas, spermatocytic seminomas, sex cord tumors, teratomas, and tumors with mixtures of several different malignant cell types.
In 2013 the American Cancer Society estimated that approx 7,900 U.S. men would be diagnosed with testicular cancers and that fewer than 400 would die of the disease.
Although specific causative factors for testicular cancer are unknown, research findings suggest a connection between the incidence of cryptorchidism (failure of the testicles to descend) and testicular cancer.
SYMPTOMS AND SIGNS
The testes may be enlarged and swollen although often there are no symptoms.
A testicular tumor can be distinguished from a hydrocele by transillumination. Because the tumor produces estrogen, inspect the patient for gynecomastia.
A testicular examination is performed. A normal testicle is egg shaped and feels smooth and firm but not hard. One testicle may naturally be larger than the other, but a change in size or the presence of a lump are considered abnormal findings. With testicular cancer, the lump is generally painless. The surrounding area should also be palpated for the presence of enlarged lymph nodes. Lymphadenopathy, especially in the abdominal and supraclavicular regions, is also found in more advanced disease. Other diagnostic tests include scrotal ultrasound; radical orchiectomy, followed by a biopsy; and serum laboratory analysis.
Three methods of treatment include surgery, radiation therapy, and chemotherapy. The use of radiation and chemotherapy depends on the staging and the type of cancer, i.e., seminomas or nonseminomatous tumors.
The patient is prepared physically and emotionally for surgery, chemotherapy, or radiotherapy. During hospitalization, all general patient care concerns apply.
The diagnosis of testicular cancer is usually devastating; the clinician should discuss the patient’s concerns with him and explain the role of hormonal replacement in maintaining the secondary sex characteristics. If the patient is at risk for sterility, explain sperm banking procedures before treatment if infertility and impotence may result from surgery. Refer the patient to a support group or ask that another patient who has received a similar diagnosis and treatment to share his experiences to provide support. If the patient or partner is struggling to cope with the diagnosis, arrange for a counselor.
SYN: SEE: germ cell tumor
Disseminated cancer in which the original tissue type is uncertain. Such cancers generally have poor prognoses.
Patients with such cancers are usually evaluated for tumors that might respond well to therapy, such as a lymphoma, a thyroid cancer, a germ cell tumor, or neoplasms of the breast or prostate.
All patients with cancers of unknown primary site should undergo CT scanning of the chest, abdomen, and pelvis with radiologic contrast. Tumor marker detection based on blood tests and tests performed on tissue biopsies may help identify the tissue of origin.
A malignant neoplasm of the uterus, usually of the endometrium, found most often in women over 50. Other uterine cancers include those that arise in the muscular wall of the uterus (sarcomas), cervical cancers, and trophoblastic cancers. Symptoms may include post menopausal bleeding, bleeding between periods, and irregular, long, heavy periods. Pain during urination and intercourse may be reported. Diagnosis of endometrial cancer is made by endometrial biopsy. The most common treatment is hysterectomy, although radiation and hormone therapy may be used.
SEE: Bethesda System, The; SEE: cervical cancer; SEE: cervical intraepithelial neoplasia
Any malignant neoplasm of the vulva. Of these, 90% are squamous cell carcinomas; the rest are caused by adenocarcinomas, sarcomas, or Paget disease.
Vulvar cancer accounts for 4% of all gynecological malignancies. More than 50% of cases occur in postmenopausal women between the ages of 65 and 70. Generally, vulvar cancers are localized, slow-growing, and marked by late metastasis to the regional lymph nodes. Treatment may include surgery and/or radiation therapy.
Estimated Number* of New Cancer Cases and Deaths by Sex, U.S., 2013*
|Estimated New Cases||Estimated Deaths|
|Both Sexes||Male||Female||Both Sexes||Male||Female|
|Oral cavity & pharynx||41,380||29,620||11,760||7,890||5,500||2,390|
|Liver & intrahepatic bile duct||30,640||22,720||7,920||21,670||14,890||6,780|
|Lung & bronchus||228,190||118,080||110,110||159,480||87,260||72,220|
|Kidney & renal pelvis||65,150||40,430||24,720||13,680||8,780||4,900|
|Brain & other nervous system||23,130||12,770||10,360||14,080||7,930||6,150|
|Breast self-examination||Breast cancer||Monthly self-examination by women is a noninvasive way to screen for changes in the breast. This method detects many benign and cancerous lumps, but its ability to prolong life is still debated.|
|Mammography||Breast cancer||Mammography is clearly effective screening in women over 50. Most mammograms are obtained by women in their 40s. The incidence of cancer is higher in later life, when mammography use tends to decline.|
|Digital rectal examination (DRE)||Colorectal cancer, prostate cancer||DRE is easy to perform and inexpensive but its cancer screening value is unproven; and, when it detects cancers, there is no proof that the test results in better patient outcomes. In addition, DRE detects a very small number of cancers, only those within the reach of the examiner.|
|Fecal occult blood test||Colorectal cancer||In people over 50, testing stool specimens for hidden bleeding detects many cancers; this detection results in earlier treatment and prolongation of life. The accuracy and value of the test relative to sigmoidoscopy and colonoscopy are uncertain.|
|Chest x-ray, sputum cytology, CT of the chest||Lung cancer||Prospective studies have yielded conflicting results for any method of screening for lung cancer in smokers, and the costs of screening, e.g., with CT of the chest, may be prohibitive. The tests are of no value to nonsmokers.|
|Prostate specific antigen (PSA)||Prostate cancer||PSA testing detects many previously undetected prostate cancers but may result in increased death and disease due to complications from subsequent surgery. Refinements in its application may improve its usefulness as a screening tool.|
|Genetic testing||For predisposition to a variety of cancers||The predictive value of genetic testing for cancer is very small. Experts are debating the emotional and ethical consequences of genetic cancer screening tests.|
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