TOPIC 7 NOTES

CANCER

Introduction

In the most basic terms, cancer refers to cells that grow out-of-control and invade other tissues.
Cells become cancerous due to the accumulation of defects, or mutations, in their DNA. Certain:

1. inherited genetic defects (for example, BRCA1 and BRCA2 mutations),

2. infections,
3. environmental factors (for example, air pollution, radioactivity), and
4. Poor lifestyle choices -- such as smoking and heavy alcohol use -- can also damage DNA
and lead to cancer.

Most of the time, cells are able to detect and repair DNA damage. If a cell is severely damaged
and cannot repair itself it undergoes so-called programmed cell death or apoptosis. Cancer occurs
when damaged cells grow, divide, and spread abnormally instead of self-destructing as they
should.

Malignant Tumors Vs. Benign Tumors

A tumor is an abnormal mass of cells. Tumors can either be benign (non-cancerous) or malignant
(cancerous).

Benign Tumors

Benign tumors grow locally and do not spread. As a result, benign tumors are not considered
cancer. They can still be dangerous, especially if they press against vital organs like the brain.

Malignant Tumors

Malignant tumors have the ability to spread and invade other tissues. This process, known as
metastasis, is a key feature of cancer. There are many different types of malignancy based on
where a cancer tumor originates.

Cancer Metastasis

Metastasis is the process whereby cancer cells break free from a malignant tumor and travel to
and invade other tissues in the body. Cancer cells metastasize to other sites via the lymphatic
system and the bloodstream. Cancer cells from the original—or primary—tumor can travel to
other sites such as the lungs, bones, liver, brain, and other areas. These metastatic tumors are
"secondary cancers" because they arise from the primary tumor.

Metastatic cancer retains the name of the primary cancer. For example, bladder cancer that
metastasizes to the liver is not liver cancer. It is called metastatic bladder cancer. Metastasis is
significant because it helps determine the staging and treatment. Some types of metastatic cancer
are curable, but many are not.
Causes of Cancer

Certain genes control the life cycle—the growth, function, division, and death—of a cell. When
these genes are damaged, the balance between normal cell growth and death is lost. Cancer cells
are caused by DNA damage and out-of-control cell growth. The following is a partial list of
factors known to damage DNA and increase the risk of cancer:

1. Mutations Cause

Genetic mutations may cause cancer. For example, mutations of genes BRCA1 and BRCA2
(linked to an increased risk of breast and ovarian cancers) can inhibit the body’s ability to safe-
guard and repair DNA. Copies of these mutated genes can be passed on genetically to future
generations, leading to a genetically-inherited increased risk of cancer.

2. Environment Cause

Cancer may be caused by environmental exposure. Sunlight can cause cancer through ultraviolet
radiation. So can air pollutants like soot, wood dust, asbestos, and arsenic, to name just a few.

3. Microbes Cause

Some microbes are known to increase cancer risks. These include bacteria like H. pylori, which
causes stomach ulcers and has been linked to gastric cancer. Viral infections (including Epstein-
Barr, HPV, and hepatitis B and C) have also been linked to cancer.

4. Lifestyle and Diet Causes

Lifestyle choices can lead to cancer as well. Eating a poor diet, inactivity, obesity, heavy alcohol
use, tobacco use including smoking, and exposure to chemicals and toxins are all associated with
greater cancer risk.

5. Treatment

Medical treatment with chemotherapy, radiation, targeted treatments (drugs designed to target a
specific type of cancer cell) or immunosuppressive drugs used to decrease the spread of cancer
throughout the body can also cause damage to healthy cells. Some “second cancers”, completely
separate from the initial cancer, have been known to occur following aggressive cancer
treatments; however, researchers are producing drugs that cause less damage to healthy cells (for
example, targeted therapy).

Cancer Symptoms and Signs

There are more than 100 different types of cancer. Every cancer and every individual is unique.
Cancer symptoms and signs depend on the size and location of the cancer as well as the presence
or absence of metastasis.

Symptoms and signs of cancer may include:

1. Fever
2. Pain
3. Fatigue
4. Skin changes (redness, sores that won't heal, jaundice, darkening)
5. Unintended weight loss or weight gain

Other more obvious signs of cancer may include:

a. Lumps or tumors (mass)

b. Difficulty swallowing
c. Changes or difficulties with bowel or bladder function
d. Persistent cough or hoarseness
e. Short of breath
f. Chest pain
g. Unexplained bleeding or discharge

Types of Cancer

Cancer can occur anywhere in the body. Broadly, cancers are classified as either solid (for
example breast, lung, or prostate cancers) or liquid (blood cancers). Cancer is further classified
according to the tissue in which it arises.

1. Carcinoma
Carcinomas are cancers that occur in epithelial tissues in the body. They comprise 80% to 90%
of all cancers. Most breast, lung, colon, skin, and prostate cancers are carcinomas. This class
includes the two most common skin cancers, basal cell carcinoma and squamous cell carcinoma.
Also in this class is the glandular cancer adenocarcinoma.

2. Sarcoma Cancer

Sarcomas occur in connective tissue like the bones, cartilage, fat, blood vessels, and muscles.
This class of cancers includes the bone cancers osteosarcoma and Ewing sarcoma, Kaposi
sarcoma (which causes skin lesions), and the muscle cancers rhabdomyosarcoma and
leiomyosarcoma.

3. Myeloma Cancer

Myelomas are cancers that occur in plasma cells in the bone marrow. This class of cancer
includes multiple myeloma, also known as Kahler disease.

4. Leukemia

Leukemias are a group of different blood cancers of the bone marrow. They cause large numbers
of abnormal blood cells to enter the bloodstream.

5. Lymphoma Cancer

Lymphomas are cancers of the immune system cells. These include the rare but serious Hodgkin
lymphoma (Hodgkin’s lymphoma, also Hodgkin’s disease) and a large group of white blood cell
cancers known collectively as non-Hodgkin lymphoma (non-Hodgkin’s lymphoma).

6. Mixed Cancer

Mixed cancers arise from more than one type of tissue.

Common Cancers
How Stages of Cancer Are Determined

Doctors use the stages of cancer to classify cancer according to its size, location, and extent of
spread. Staging helps doctors determine the prognosis and treatment for cancer. The TNM
staging system classifies cancers according to:

1. Tumor (T): Primary tumor size and/or extent

2. Nodes (N): Spread of cancer to lymph nodes in the regional area of the primary tumor
3. Metastasis (M): Spread of cancer to distant sites away from the primary tumor
Some cancers, including those of the brain, spinal cord, bone marrow (lymphoma), blood
(leukemia), and female reproductive system, do not receive a TNM classification. Instead, these
cancers are classified according to a different staging systems.

The Stages of Cancer

The TNM classification of a cancer usually correlates to one of the following five stages.

1. Stage 0: This refers to cancer that is "in situ," meaning that cancerous cells are confined
to their site of origin. This type of cancer has not spread and is not invading other tissues.
2. Stage I – Stage III: These higher stages of cancer correspond to larger tumors and/or
greater extent of disease. Cancers in these stages may have spread beyond the site of
origin to invade regional lymph nodes, tissues, or organs.
3. Stage IV: This type of cancer has spread to distant lymph nodes, tissues, or organs in the
body far away from the site of origin.

Diagnosing Cancer

Various tests may be performed in order to confirm a cancer diagnosis. Positron Emission
Tomography and Computed Tomography (PET-CT) Scans and other similar tests can highlight
“hot spots” of cancer cells with high metabolic rates.

The most common test and procedures used to diagnose cancer include:

1. Mammogram
2. Pap Test
3. Tumor Marker Test
4. Bone Scan
5. MRI
6. Tissue Biopsy
7. PET-CT Scan

The Role of Lymph Nodes in Cancer Diagnosis

Cancer that originates in the lymph nodes or other area of the lymphatic system is called
lymphoma. Cancer that originates elsewhere in the body can spread to lymph nodes. The
presence of metastasized cancer in the lymph nodes is may mean the cancer is growing quickly
and/or is more likely to spread to other sites. The presence of cancer in lymph nodes often affects
prognosis and treatment decisions. Many diagnostic tests look at the lymph nodes as an indicator.

Treatment of Cancer

The treatment is highly variable depending on the type and stage of a cancer as well as the
overall health of the patient. The most common treatments are surgery, radiation, and
chemotherapy. Other treatments include targeted/biological therapies, hematopoietic stem cell
transplants, angiogenesis inhibitors, cryosurgery, and photodynamic therapy.

Every treatment has potential risks, benefits, and side effects. The patient and his or her care
team, which may include an internist or other specialist, surgeon, oncologist, radiation
oncologist, and others, will help determine the best and most appropriate course of treatment.

1. Surgery

Surgery is often performed to remove malignant tumors. Surgery allows for the determination of
the exact size of the tumor as well as the extent of spread and invasion into other nearby
structures or lymph nodes – all-important factors in prognosis and treatment. Surgery is often
combined with other cancer treatments, such as chemotherapy and/or radiation.

Sometimes, cancer cannot be entirely surgically removed because doing so would damage
critical organs or tissues. In this case, debulking surgery is performed to remove as much of the
tumor as is safely possible. Similarly, palliative surgery is performed in the cases of advanced
cancer to reduce the effects (for example, pain or discomfort) of a cancerous tumor. Debulking
and palliative surgeries are not curative, but they seek to minimize the effects of the cancer.

Reconstructive surgery can be performed to restore the look or function of part of the body after
cancer surgery. Breast reconstruction after a mastectomy is an example of this kind of surgery.

2. Radiation Therapy

Radiation is a very common cancer treatment. About 50% of all cancer patients will receive
radiation treatment, which may be delivered before, during, or after surgery and/or
chemotherapy. Radiation can be delivered externally -- where X-rays, gamma rays, or other
high-energy particles are delivered to the affected area from outside the body -- or it can be
delivered internally. Internal radiation therapy involves the placement of radioactive material
inside the body near cancer cells. This is called brachytherapy.

Systemic radiation involves the administration of radioactive medication by mouth or

intravenously. The radioactive material travels directly to the cancerous tissue. Radioactive
iodine (I-131 for thyroid cancer) and strontium-89 (for bone cancer) are two examples of
systemic radiation treatments.
Typically, external radiation is delivered 5 days a week over the course of 5 to 8 weeks. Other
treatment regimens are sometimes used.

3. Chemotherapy

Chemotherapy, or "chemo," refers to more than 100 different medications used to treat cancer
and other conditions. If eliminating all cancer cells is not possible, the goals of treatment may be
to slow the growth of the cancer, keep the cancer from spreading, and/or relieve cancer-
associated symptoms (such as pain).

Depending on the type of chemotherapy prescribed, the medications may be given by mouth,
injection, intravenously (IV), or topically. IV chemotherapy may be delivered via a catheter or
port, which is usually implanted in a blood vessel of the chest for the duration of the therapy.
Sometimes chemotherapy is delivered regionally, directly to the area that needs treatment. For
example, intravesical therapy is used to infuse chemotherapy directly into the bladder for the
treatment of bladder cancer.

The chemotherapy regimen a patient receives depends upon the type and stage of the cancer, any
prior cancer treatment, and the overall health of the patient. Chemotherapy is usually
administered in cycles over the course of days, weeks, or months, with rest periods in between.

Other Treatments

4. Targeted or Biological Therapies

Targeted or biological therapies seek to treat cancer and boost the body's immune system while
minimizing damage to normal, healthy cells. Monoclonal antibodies, immunomodulating drugs,
vaccines, and cytokines are examples of targeted or biological therapies.

5. Hematopoietic Stem Cell Transplants

Hematopoietic stem cell transplants involve the infusion of stem cells into a cancer patient after
the bone marrow has been destroyed by high-dose chemo and/or radiation.

6. Angiogenesis Inhibitors

Angiogenesis inhibitors are medications that inhibit the growth of new blood vessels that
cancerous tumors need in order to grow.

7. Cryosurgery

Cryosurgery involves the application of extreme cold to kill precancerous and cancerous cells.

8. Photodynamic Therapy
Photodynamic therapy (PDT) involves the application of laser energy of a specific wavelength to
tissue that has been treated with a photosensitizing agent, a medication that makes cancerous
tissue susceptible to destruction with laser treatment. Photodynamic therapy selectively destroys
cancer cells while minimizing the damage to normal, healthy tissues nearby.

9. Ongoing Research

Ongoing cancer research continues to identify newer, less toxic, and more effective cancer
treatments.

Prevention of Cancer

Until a cure can be found, prevention through a healthy lifestyle is the best way to stop cancer.
Some ways to help protect yourself from cancer include:

a. eating plenty of fruits and vegetables,

b. maintaining a healthy weight,
c. abstaining from tobacco,
d. drinking only in moderation,
e. exercising
f. avoiding sun damage,
g. avoid exposure to causative agents in the environment
h. getting immunizations
i. Getting regular health screenings.