Four thousand women and men began a 60-mile pilgrimage yesterday to kick off this year's annual San Diego Breast Cancer 3-Day walk.
Bystanders cheered as swarms of walkers, some clad in outfits featuring pink feather boas and rhinestone bras, made their way from the Del Mar Fairgrounds to Kellogg Park in La Jolla, where they stopped for lunch. Team names – such as the Heart and Sole Sisters and The Hakuna Ma-Ta-Tas – were spotted on shirts and signs.
“Good job, ladies!” shouted Joni Birse of Ramona as a group in pink tutus, tiaras and hula skirts strutted down the boardwalk, ready to eat after 11 miles of hoofing.
San Diego native Maria Sevier, who now lives Tacoma, Wash., said the experience has been inspiring.
“It's phenomenal,” Sevier said as she stretched on the grass. “I walk because I have a cousin who has been battling breast cancer for seven years.” Nearby, Elizabeth Ferry, 18, and Kathy Garat, 43, both from El Cajon, fueled up on chicken sandwiches and apples.
“We've got another nine miles to go today,” Garat said. “We're feeling good. No blisters yet.”
Maury O'Connor, 20, and Megan Fennell, 21, flew in from New Jersey to support a family friend with breast cancer. Catherine Wagner and Dotte Collins, both from Dallas, wanted a change of scenery.
“This our third 3-Day,” said Wagner, 27. “We did the first two in Texas. This route is so much prettier than the one from Fort Worth to Dallas.”
Jessi Grant, 65, journeyed from South Dakota to cheer on her daughter, a cancer survivor.
“Both my daughters had breast cancer,” Grant said. “One died at 29. It's hard to face losing the only other one I have.”
Of all 14 walks around the country, San Diego's is the biggest in terms of participation and money raised, officials said. Each walker commits to raising at least $2,200. Proceeds support breast cancer research, education, outreach and treatment.
Saturday, November 22, 2008
Finding Ways to Help Children With Cancer
On doing acupuncture on small children: We use much smaller needles. Oftentimes with kids it’s easier to deal with the kid when they’re doing what they want to do. It’s like, “Keep playing with the toy; we’ll do what we’ve got to do.”
How it can help: We use it a lot for nausea and vomiting if they’re having chemotherapy, for fatigue, to increase appetite, and for headaches, stress, dry mouth, pain from radiation. I sit in on rounds with the medical team. We’re constantly conversing about who we should go see.
What children pick first from the program’s free offerings: Aromatherapy. It works for anxiety. During a bone marrow transplant or stem cell transplant, the preservative used to treat the stem cells has a strong odor, and we use aromatherapy to help calm children and their families. We have a million and one different essential oil bottles here. Choosing is quite an empowering thing to them. They love it.
Big things in small office: Two computers, five chairs, a massage table, sink, Pilates machine, upended treadmill with a medicine ball on it, heat lamp, yoga mats.
Jumping-off point: I worked at the Showtime network, at its in-house advertising department. It was as uncorporate as a corporate job could get. Then 9/11 happened, and I did a re-evaluation of how I wanted to spend time. I did research on careers that would address all my passions. I wanted to work with my hands, work one-on-one with people, do Chinese medicine, and acupuncture. I called people in the Yellow Pages and asked, “Do you like your job?” I talked to naturopaths, acupuncturists and nutritionists.
Coolest semester off: Being a chef in an organic vineyard in Provence.
On getting sick youngsters to eat better: I teach them about plant-based protein, like tempeh and tofu. We go on a supermarket scavenger hunt, going to different places in the supermarket than they’re used to going. Broccoli and brussels sprouts — they love them. We roast them, which makes everything sweeter.
In free time with new husband: We cook a lot. He bakes bread, and I cook. We really cook all our meals at home, and bring lunch. People ask: “How do you do that? You should start a blog.”
Worst days: Some days are really hard if patients I’ve become close to have a relapse, or they’ve found progression of the disease. That’s always hard. But we can always offer families our services wherever they are in cancer treatment or survivorship. What we can do is help them feel better right then. If parents feel better, they’ll be there for their kids more, and if kids feel better, they can fight with more gusto.
Best perk: You see it every day, you see the grace, you see the hope, you see the love that permeates everything this department does. We’re dealing with a lot: kids that are dying, kids that are around kids who are dying. Of course, there’s a perspective to be kept, but I learn that just about anything is possible.
How it can help: We use it a lot for nausea and vomiting if they’re having chemotherapy, for fatigue, to increase appetite, and for headaches, stress, dry mouth, pain from radiation. I sit in on rounds with the medical team. We’re constantly conversing about who we should go see.
What children pick first from the program’s free offerings: Aromatherapy. It works for anxiety. During a bone marrow transplant or stem cell transplant, the preservative used to treat the stem cells has a strong odor, and we use aromatherapy to help calm children and their families. We have a million and one different essential oil bottles here. Choosing is quite an empowering thing to them. They love it.
Big things in small office: Two computers, five chairs, a massage table, sink, Pilates machine, upended treadmill with a medicine ball on it, heat lamp, yoga mats.
Jumping-off point: I worked at the Showtime network, at its in-house advertising department. It was as uncorporate as a corporate job could get. Then 9/11 happened, and I did a re-evaluation of how I wanted to spend time. I did research on careers that would address all my passions. I wanted to work with my hands, work one-on-one with people, do Chinese medicine, and acupuncture. I called people in the Yellow Pages and asked, “Do you like your job?” I talked to naturopaths, acupuncturists and nutritionists.
Coolest semester off: Being a chef in an organic vineyard in Provence.
On getting sick youngsters to eat better: I teach them about plant-based protein, like tempeh and tofu. We go on a supermarket scavenger hunt, going to different places in the supermarket than they’re used to going. Broccoli and brussels sprouts — they love them. We roast them, which makes everything sweeter.
In free time with new husband: We cook a lot. He bakes bread, and I cook. We really cook all our meals at home, and bring lunch. People ask: “How do you do that? You should start a blog.”
Worst days: Some days are really hard if patients I’ve become close to have a relapse, or they’ve found progression of the disease. That’s always hard. But we can always offer families our services wherever they are in cancer treatment or survivorship. What we can do is help them feel better right then. If parents feel better, they’ll be there for their kids more, and if kids feel better, they can fight with more gusto.
Best perk: You see it every day, you see the grace, you see the hope, you see the love that permeates everything this department does. We’re dealing with a lot: kids that are dying, kids that are around kids who are dying. Of course, there’s a perspective to be kept, but I learn that just about anything is possible.
PERSONALIZED THERAPY IMPROVES SURVIVAL
AGGRESSIVE, PERSONALIZED THERAPY IMPROVES SURVIVAL
and Select Those Who May Respond to Targeted Therapies
A study of nearly 1,500 patients treated for kidney cancer at UCLA in the last 15 years shows that an aggressive, tailored treatment approach results in better survival rates and uncovered subsets of kidney cancer that behave differently and need to be treated accordingly.
The one-size-fits-all approach traditionally used in kidney cancer treatment should be changed based on the results of the study, the longest to date to analyze kidney cancer patients and their outcomes, said Dr. Arie Belldegrun, senior author of the study, a professor of urology and a researcher at UCLA’s Jonsson Comprehensive Cancer Center.
“This is the most important work that we’ve done out of the kidney cancer program at UCLA,” Belldegrun said. “We outline the foundation for personalized kidney cancer therapy. We have shown that not all kidney cancer patients are the same, not all localized kidney cancers are the same and not all metastatic kidney cancers are the same.”
The study appears in the Nov. 1, 2008 issue of Cancer, the peer-reviewed journal of the American Cancer Society.
The study found that patients with localized kidney cancer, cancer that has not spread to other organs, could have either low, intermediate or high risk cancers based on the chance for recurrence. Patients with cancers that have already spread also fell into similarly different subsets. Some have better outcomes while others may have very aggressive cancers that may not warrant treatment.
“We showed for the first time, using an integrated staging system developed at UCLA, that we can identify which patients with localized disease fall into the low, intermediate and high risk subsets and which patients with metastasized cancers are either low, intermediate or high risk patients,” Belldegrun said. “Now we can make treatment decisions based on that.”
If a patient with localized cancer is identified as low risk, his five-year survival rate is expected to be 97 percent, while his 10-year survival rate is 92 percent. An intermediate risk patient with localized disease would have a five-year survival rate of 81 percent and a 10-year survival rate of 61 percent. A high risk patient has a five-year survival rate of 62 percent, with a 10-year survival of 41 percent.
“All of these patients with cancers that have not spread present to their doctors with presumably localized disease and in the past they may have been treated the same way,” Belldegrun said. “They need to be treated individually according to their risk levels.”
The study showed that a patient with low-risk, localized kidney cancer could be treated only with surgery and expect an excellent outcome. Such a move would spare the patient from having to undergo radiation or immunotherapy, which result in harsh side effects. However, for a patient with high-risk, localized kidney cancer, surgery would not be enough. Additional therapy such as targeted treatments or immunotherapy should be considered in order to give the patient the best possible outcome.
In metastatic patients, someone with low-risk cancer should get very aggressive treatment, Belldegrun said, because there’s a good chance the therapy will help the patient. Those with high-risk, metastatic disease won’t get much, if any, benefit from treatment and may want to forego surgery and the toxic therapies.
“Our paper identifies, very precisely, which patients should get which therapies,” Belldegrun said.
The study represents 15 years of experience in UCLA’s leading-edge kidney cancer program, an interdisciplinary approach to treating cancer that brings together medical oncologists, urologists, surgeons, clinical trials experts and scientists under one roof, a concept that was first conceptualized at UCLA. The study analyzed the first 1,492 patients treated in the program and “demonstrated that outstanding results can be achieved using this approach,” Belldegrun said.
About 25 percent of the patients with metastatic kidney cancer achieved long-term responses – five to 15 year survivals – from their therapy, Belldegrun said. Less than 5 percent of metastatic kidney cancer patient typically achieve long term survivals or a cure when treated with conventional treatments.
“This is by far the best survival data in such a difficult group of patients,” Belldegrun said. “This can be achieved today only in kidney cancer centers of excellence like we are operating at UCLA, where we have all the expertise at hand, the best scientists, clinicians and surgeons working together.”
The results of the study come as new targeted therapies are being introduced specifically for kidney cancer. The U.S. Food & Drug Administration has recently approved three such drugs. Belldegrun said the survival rates detailed in their paper should be used as a benchmark to which these new therapies should be compared.
“While the field of kidney cancer is undergoing dramatic changes it is as yet still unclear how these changes are affecting patient outcome,” the study states. “A critical assessment of the potential improvement in the new treatment era necessitates a comparison to a known benchmark. We present long-term, single institution data to provide a thorough understanding of the results that have been achieved until now using a consistent, aggressive approach for localized and metastatic disease. For future patient care, it will be important to select patients that will do best using existing therapies, and those who should be treated using the newly approved treatments.”
Other lead investigators on the study include Dr. Fairooz Kabbinavar, medical director of the kidney cancer program at UCLA and a professor of hematology/oncology, and Dr. Allan Pantuck, director for translational research and an associate professor of urology. Both are scientists with the Jonsson Cancer Center.
UCLA's Jonsson Comprehensive Cancer Center comprises about 235 researchers and clinicians engaged in disease research, prevention, detection, control, treatment and education. One of the nation's largest comprehensive cancer centers, the Jonsson center is dedicated to promoting research and translating basic science into leading-edge clinical studies. In July 2008, the Jonsson Cancer Center was named among the top 10 cancer centers nationwide by U.S. News & World Report, a ranking it has held for nine consecutive years. For more information on the Jonsson Cancer Center, visit our website at http://www.cancer.ucla.edu.
Ovarian Cancer
About Ovarian Cancer
The ovaries are a pair of almond-shaped organs located in the pelvis on either side of the uterus. They are about 1-1/2 inches long in a young woman, but they shrink to about half their original size after menopause. The function of the ovaries is to produce eggs and female sex hormones; they also regulate the menstrual cycle and pregnancy.
A cancerous tumor that originates in the ovaries is called ovarian cancer. There are many different forms of this cancer, but most types begin in the cells that make up the outer lining of the ovary. These are called epithelial ovarian cancers.
In recent years, research has identified many of the risk factors associated with ovarian cancer. Significant progress has also been made in the treatment of the disease. Although these advances have not yet had a dramatic impact on the cure rate for advanced ovarian cancer, they are helping patients to live longer.
Each year, approximately 25,500 women are diagnosed with ovarian cancer, and 14,500 die of the disease.
Cancer FAQs
Why is ovarian cancer so deadly?
Ovarian cancer accounts for more deaths in the United States than any other gynecologic cancer. Hidden symptoms and a lack of reliable earlydetection tests are to blame. Over 70 percent of all women with ovarian cancer are not diagnosed until the disease has spread beyond the ovary. At this stage, the likelihood of living for five years after diagnosis is between 20 percent and 25 percent. By contrast, at least 90 percent of women who are fortunate enough to have their cancer diagnosed and treated early, when the cancer is still confined to one or both ovaries, will survive for five years or more.
Is ovarian cancer hereditary?
About 5-10 percent of ovarian cancer cases are related to inherited factors. Concern about family history and genetic predisposition to ovarian and breast cancers has been heightened by the recent identification of BRCA1 and BRCA2, the breast-cancer susceptibility genes. Normally, BRCA genes help to prevent cancer, but if a woman inherits a mutated (defective) form, her ovaries and breasts are more susceptible to cancer. In fact, depending on the mutation, women who carry a defective BRCA gene have a lifetime risk of ovarian cancer of about 20 percent. This is dramatically higher than the average woman’s lifetime risk, which is 1.8 percent (about one in 57 women). In addition, ovarian cancer occurs an average of 20 years earlier in BRCA gene-mutation carriers compared to non-carriers.
A woman with two first-degree relatives (a mother, sister or daughter) with breast or ovarian cancer may wish to consult a genetic counselor about testing for the BRCA mutations. Women who test positive for a mutation should consider the various preventive measures available [see question below, “Can I do anything to prevent ovarian cancer?”]. Bear in mind that having only one first-degree relative with ovarian cancer makes the likelihood of carrying a BRCA gene mutation very low. However, ovarian cancer in one first-degree relative does raise a woman’s lifetime risk of the disease from
1.8 percent to about 5 percent.
What are the risk factors associated with ovarian cancer?
The specific causes of ovarian cancer are not known. But every woman who has intact ovaries is at risk for ovarian cancer. The individual level of risk depends on a woman’s family history [see question above,“Is ovarian cancer hereditary?”], age and reproductive history.
Risk increases with age. Ovarian cancer is most common in postmenopausal women, occurring at an average age of 61 years.
Other risk factors include:
- a personal history of breast, uterine, or colon cancer;
- a family history of ovarian, breast, or colon cancer, especially in a mother, sister, or daughter;
- early age at first menstruation (before age 12);
- late age at menopause (after age 52);
- never having children or not having children until late in life (after age 35);
- use of talcum powder in the genital area. (Cornstarch powder is a safe alternative.)
Anything that suppresses ovulation in the premenopausal years reduces ovarian-cancer risk. For example, having more than one full-term pregnancy, breast-feeding, use of oral contraceptives, tubal ligation, and removal of the ovaries all lower a woman’s risk.
Can I do anything to prevent ovarian cancer?
Unfortunately, specific dietary strategies for staving off ovarian cancer have not been proven in research studies. However, healthful living has been linked to a reduction in the risk of all cancers in general. Exercising regularly, eating a diet high in fruits, vegetables, and grains, and not smoking are all protective behaviors. For ovarian cancer specifically, avoiding the use of talcum-based powders in the genital area is also a good idea.
For women considered at particularly high risk – women with two firstdegree relatives with ovarian cancer and women who carry a BRCA gene mutation – some experts recommend regular ultrasonography and CA-125 screening tests, although many early-stage cancers may still be missed. [See question below,“ What diagnostic tests are used to identify ovarian cancer?”]
High-risk premenopausal women should consider taking oral contraceptives. Studies show that the risk of ovarian cancer is reduced by 50 percent in women who take birth-control pills for five years, and by 75 percent in women who take birth-control pills for 10 years or more. For high-risk perimenopausal and postmenopausal women, gynecologists generally recommend preventive removal of the ovaries, called prophylactic oophorectomy (pronounced oh-uh-fuh-REK-tuh-mee). In most cases, high-risk women can safely delay oophorectomy until about age 40, to allow completion of childbearing, because the incidence of ovarian cancer is lower before that age. A high-risk menopausal woman who needs to have abdominal surgery for any reason, even non-gynecological surgery, should discuss prophylactic removal of the ovaries with her surgeon.
What are the symptoms of ovarian cancer?
When an ovarian tumor develops and grows, it takes up extra space in the abdominal cavity, potentially causing vague feelings of bloating or discomfort. These symptoms can easily be attributed to gastrointestinal problems, menstrual changes, weight gain or other minor conditions. This is why ovarian cancer has earned its reputation as a “silent” disease – the symptoms are so mild and ambiguous that they are easily ignored.
If any of the following symptoms persists for more than a few weeks, it could be an early sign of ovarian cancer:
- Feelings of abdominal bloating or swelling;
- General discomfort in the pelvic area;
- Loss of appetite or feelings of fullness, even after a light meal;
- Gastrointestinal symptoms, such as gas, indigestion and nausea;
- Change in bowel movements and urination;
- Abnormal vaginal bleeding;
- Pain during sexual intercourse;
- Unusual fatigue.
See your doctor to investigate the cause of any persistent symptoms.
What diagnostic tests are used to identify ovarian cancer?
To investigate the cause of any symptoms, the first step is a pelvic examination, in which the doctor feels the ovaries, fallopian tubes, uterus, vagina, rectum, bladder and lower abdomen for any growths. Tests for gastrointestinal problems may be ordered next, but two specific tests for ovarian cancer should also be performed.
The first test is a transvaginal pelvic ultrasound, in which high-frequency sound waves are used to produce computer images of the vagina, uterus, ovaries, fallopian tubes and bladder. Ultrasound can often differentiate between malignant (cancerous) tumors and benign (noncancerous) growths, such as ovarian cysts.
The second test is a CA-125 blood test.CA-125 is a tumor marker – a substance often found to be at elevated levels in the blood when cancer is present in the body. Although an increased level of CA-125 frequently indicates cancer, the test is not precise.CA-125 levels may also be high in women who have benign ovarian conditions and in women who are ovulating.What’s more, not all women with ovarian cancer have elevated CA-125. Increased levels are present only in about 80 percent of women with advanced ovarian cancer and 50 percent of women with early-stage disease.
Results of these two tests suggest whether ovarian cancer is likely to be present, but neither test is accurate enough to make a definitive diagnosis. Only surgery to explore the ovaries and other organs in the abdomen can tell for sure if ovarian cancer is present. Of the women who undergo exploratory surgery for ovarian cancer, less than 20 percent are diagnosed with the disease.
What are the stages of ovarian cancer?
The initial surgery used to diagnose ovarian cancer also involves staging. Examination of the fluid and tissue samples removed during surgery (biopsy samples) indicates the type of cancer cells present and how far the cancer has spread. Staging determines whether more extensive surgery or other treatments may be needed.
The four basic stages of ovarian cancer are:
Stage I: Cancer growth is limited to one or both ovaries.
Stage II: Cancer has spread beyond the ovary, but is limited to the pelvic cavity (uterus, fallopian tubes or other structures in the pelvis).
Stage III: Cancer is found in one or both ovaries, in the pelvis and also in the abdominal cavity and/or nearby lymph nodes.
Stage IV: Cancer has spread outside the ovary and abdomen (called distant metastases) or to the liver.
How is ovarian cancer treated?
As with all cancers, treatment depends on the stage of the disease and the patient’s overall health. There are two main treatment approaches.
Surgery to remove the cancerous growth(s) is the primary method of treatment and is performed at the same time as the initial, diagnostic surgery. Both ovaries, the fallopian tubes, the uterus and the cervix are usually removed. The surgeon may also remove the omentum, a thin layer of fatty tissue covering the stomach and large intestine.
If cancer is found at an early stage in a young woman, fertility-sparing treatment, in which only the affected ovary is removed, is sometimes possible.
Most ovarian cancers have reached Stage III by the time they are detected, but the chances of longer survival with good quality of life have greatly improved, thanks to recent advances in chemotherapy. Chemotherapy is used immediately following surgery to kill any cancer cells that may remain in the body. Research completed in only the past few years has shown that a six-week treatment course of a two-drug combination of paclitaxel (Taxol) and intravenous platinum [carboplatin (Paraplatin) or cisplatin (Platinol)] is the most effective initial therapy.
Other chemotherapy drugs and varying drug combinations are used to treat cancers that are resistant to standard chemotherapy as well as any cancer recurrences. Radiation therapy is not routinely used but may help to relieve pain in late-stage ovarian cancer.
Recent research has reported promising results for several new treatment drugs, particularly doxorubicin (Doxil), topotecan (Hycamtin), and gemcitabine (Gemzar). Clinical trials of these drugs and others, including trastuzumab (Herceptin), the first of a new class of drugs known as monoclonal antibodies, vaccines, and hormonal agents such as tamoxifen (Nolvadex), are now under way.
Leukemia
About Leukemia
Leukemia is cancer of the blood cells. The disease develops when the body produces large numbers of abnormal blood cells, usually white blood cells, which look different from healthy cells and do not function properly. Leukemia starts in the bone marrow but can then spread to the blood, lymph nodes, spleen, liver, central nervous system and other organs.
It is estimated there were 30,800 new cases of leukemia in the United States in the year 2000.
How are blood cells supposed to work? What goes wrong in leukemia?
Blood is made up of fluid called plasma and three types of blood cells:
White blood cells help the body fight infections and other diseases. There are several different kinds of white blood cells, each with a specific role in warding off infections. The three main types are granulocytes, monocytes, and lymphocytes. (The suffix “-cyte” means cell.)
Red blood cells carry oxygen from the lungs to tissues throughout the body. They then transport carbon dioxide away from the tissues back to the lungs.
Platelets help the body to control bleeding by forming blood clots.
Blood cells are made in the bone marrow – the soft, spongy center of bones. Early, immature blood cells are called stem cells. In a healthy person, stem cells grow in a controlled, orderly manner, maturing into red blood cells, white blood cells and platelets, as the body needs them.
Leukemia results when the process of maturation from stem cell to white blood cell goes awry, producing a genetic change that disrupts the normal control of cell division. The affected cells become cancerous, multiplying rapidly without any order. Eventually, the cancerous (leukemic) cells take over the bone marrow, replacing the normal cells that make healthy blood cells. The leukemic cells may also spread to other organs, including the liver, spleen, lymph nodes, kidneys and brain.
What are the different types of leukemia?
Leukemia has many different types and subtypes. They are categorized by how fast they progress and which types of white blood cells are affected. Acute leukemias spread quickly; chronic leukemias spread more slowly. Lymphocytic leukemias affect lymphocytes; myeloid (also called myelogenous) leukemias affect either granulocytes or monocytes.
The four major forms of leukemia are:
- acute lymphocytic leukemia (ALL):
- acute myeloid leukemia (AML);
- chronic lymphocytic leukemia (CLL);
- chronic myeloid leukemia (CML).
Chronic leukemias predominantly affect adults. Acute leukemias occur in both adults and children. Acute lymphocytic leukemia is the most common type of leukemia in young children.
What causes leukemia?
The cause of leukemia in humans is unknown. However, viruses have been shown to cause some leukemias in animals, such as cats. In people, a virus called HTLV-1 (human T-cell lymphotropic virus type I) is strongly suspected to cause a rare type of leukemia, adult T-cell leukemia.
What are the risk factors associated with leukemia?
Exposure to radiation and certain chemicals, such as benzene, is associated with an increased risk of developing leukemia. So, too, is the use of some chemotherapy drugs used to treat certain cancers. In addition, people who have certain genetic disorders, such as Down syndrome and Fanconi’s syndrome, are more likely to get leukemia. As with all cancers, smoking is also a known risk factor.
What are the symptoms of leukemia?
When the bone marrow fails to produce enough normal blood cells, various symptoms arise. Because people with leukemia have too few healthy white blood cells to fend off infections, they tend to get repeated infections and fevers. Leukemia sufferers also have fewer than the normal number of healthy red blood cells, which means there are not enough red blood cells to carry oxygen to cells throughout the body. This condition is called anemia and causes patients to look pale as well as to feel weak and fatigued. Leukemia can also result in too few healthy platelets, which are responsible for blood clotting. This makes patients bruise and bleed easily, often in the form of nosebleeds, bleeding gums, and purple skin blotches.
In acute leukemia, symptoms get worse quickly and people with the disease usually visit the doctor because of the symptoms.With chronic leukemia, however, symptoms may not appear for a long time and, when they do appear, they are usually mild and worsen gradually. For this reason, chronic leukemia is often found accidentally during a routine check-up, before any symptoms develop.
How is leukemia detected?
Routine blood tests, such as a complete blood count (CBC), are often the first indication that a person has leukemia. People with leukemia usually have too many white blood cells, too few red blood cells, and too few platelets. In addition, very immature white blood cells called blasts are observed in blood samples when examined under a microscope. Blasts are not normally found in circulating blood, and they do not work the way mature cells do. Their presence alone is strong enough evidence to diagnose leukemia.
Bone marrow aspiration or a bone marrow biopsy is almost always done to confirm a diagnosis of leukemia and to determine the type. In bone marrow aspiration, a thin needle is inserted into a large bone (usually the hip) and is used to draw out a small sample of liquid bone marrow. In a bone marrow biopsy, a larger needle is used to remove a small cylinder of bone and bone marrow.
If leukemic cells are found in the bone marrow sample, the doctor will order several laboratory tests to find out how far the disease has progressed. The series of tests may include a spinal tap (lumbar puncture), in which a needle is inserted into the spinal cavity in the lower back to draw out a sample of cerebrospinal fluid – the fluid that fills the spaces in and around the brain and spinal cord. The fluid sample is examined for leukemic cells. Imaging tests, such as x-rays, may also be ordered to check for signs of leukemia in other organs.
How is leukemia classified?
Although most cancers are classified in stages that define the size of the tumor and how far the cancer has spread, this staging system is not used for leukemia. The reason is that leukemia does not usually form a mass or tumor. Rather, it affects all the bone marrow and often has already spread to other organs.
Leukemias are classified based on the results of lab tests that define several features of the disease, such as the number of white blood cells in the blood and bone marrow, the presence or absence of anemia, the platelet count, and the size of the spleen (a blood-forming organ in early life and later a storage organ for red blood cells and platelets). The doctor uses these features to guide the patient’s treatment plan.
How is leukemia treated?
Most patients with leukemia are treated with chemotherapy. Some also have stem cell transplantation or interferon therapy.
Chemotherapy (the use of cancer-killing drugs that enter the bloodstream and travel throughout the body) is the mainstay of leukemia treatment. It usually involves a combination of several anticancer drugs given over a period of time, often in cycles, but the specific treatment schedule depends on the type of leukemia a patient has. Because treatment destroys bone marrow cells, the patient may need to have red blood cells transfusions to treat anemia, platelet transfusions to control bleeding, and powerful antibiotics to treat or prevent infections.
In addition to the usual side effects associated with chemotherapy, such as temporary hair loss, nausea, vomiting, and loss of appetite, a condition called tumor lysis syndrome may result from the destruction of leukemia cells. When leukemic cells die, they release substances into the bloodstream that can harm the kidneys, the heart and the nervous system. Fortunately, tumor lysis syndrome, which is more common in people with acute leukemia than in people with chronic leukemia, can be prevented by giving the patient extra fluids or certain drugs that help the body to cleanse itself of toxins.
Stem cell transplantation provides doctors with a way to use very high doses of chemotherapy for more effective treatment. This complex therapy involves harvesting stem cells (primitive blood cells) from the bone marrow or the blood stream in a process called apheresis. The stem cells can be collected from the patient or a suitable donor. (For people with acute leukemia, the cells are usually taken from a donor, as it can be difficult to find cancer-free cells in the patient’s own marrow.) The patient is then given extremely high doses of chemotherapy and may also get total body radiation to kill any remaining cancer cells. Afterward, the stored stem cells are given to the patient as a blood transfusion. If successful, it takes about two to three weeks after the stem cells are infused for the cells to start making new white blood cells. They then start making platelets, followed by red blood cells.
Interferon therapy is another treatment option for some types of leukemia. Interferons are natural substances produced by the body and can help the immune system to normalize the bone marrow by slowing the growth of leukemic cells. Interferon therapy is usually administered as a shot given once a day. Side effects include bone pain, muscle aches, headaches, fatigue, cloudy thinking, and nausea. There are drugs, however, that can ease these side effects during therapy.
Kidney Cancer
About Kidney Cancer
Like most cancers, kidney cancer is named for the part of the body in which it originates. The kidneys are two large, bean-shaped organs located on each side of the spine just above the waist. Their function is to filter the blood and rid the body of liquid waste. As blood flows through the kidneys, tiny tubules filter out excess water, mineral salts and toxins. The kidneys concentrate these waste products into urine, which collects in the middle of each kidney in an area called the renal pelvis (renes is the Latin word for kidneys). Urine exits the kidneys through long, slender tubes called ureters. The ureters are connected to the bladder, where urine is stored until a person urinates.
In the United States, there will be approximately 30,800 new cases of kidney cancer (18,700 in men and 12,100 in women) in 2001, according to the American Cancer Society. About 12,100 people (7,500 men and 4,600 women) will die from the disease.
What are the different types of kidney cancer?
By far the most common type of kidney cancer is renal cell carcinoma, accounting for about 85 percent of cases. There are five main forms of renal cell cancers, each differentiated by the way the cancerous cells appear under a microscope. They include: clear cell (about 70–80 percent of renal cell cancers), papillary (about 10–15 percent of renal cell cancers), chromophobe (about 5 percent), collecting duct (very rare), and “unclassified,” which means the appearance of the cancer cells doesn’t fit into any of the other four main categories (about 5 percent). The type of renal cell carcinoma is important when planning a treatment strategy.
Less common forms of kidney tumors include: transitional cell carcinoma,Wilms’ tumor, renal sarcoma, renal cell adenoma, renal oncocytoma, and angiomyolipoma. Of these types of kidney tumors, transitional cell carcinomas are the most common, accounting for 5–10 percent of cases. This type of cancer begins in the renal pelvis, where the kidney connects to the ureter. The cells look and act in a manner very similar to bladder cancer. [See Bladder Cancer FAQ for more information.]
Wilms’ tumor is the predominant form of kidney cancer found in children. It rarely occurs in adults. About 5–6 percent of all kidney cancers are Wilm’s tumors. Renal sarcomas originate within the connective tissue of the kidney and account for less that one percent of all kidney cancers. The remaining types of kidney tumors – renal adenomas, oncocytomas, and angiomyolipomas – are benign (noncancerous) tumors and are rare.
Note:The remaining information in this Kidney Cancer FAQ pertains only to renal cell carcinomas.Additional information about renal cell carcinomas as well as the less common forms of kidney tumors can be obtained from the National Cancer Institute by calling 1-800-422-6237.
What are the risk factors for kidney cancer?
A risk factor is anything that increases a person’s chance of getting a disease. The leading risk factor for renal cell carcinoma is smoking, with approximately 30 percent of cases in men and 25 percent of cases in women directly attributable to the habit. Research indicates that smokers have double the risk of developing kidney cancer, compared with nonsmokers. This is because some of the carcinogens (cancer-causing substances) from tobacco smoke are absorbed from the lungs and enter the bloodstream. These chemicals are then filtered from the blood by the kidneys, where they can injure kidney cells, potentially causing cancer.
Another risk factor for kidney cancer is workplace exposure to asbestos (an insulating material that is currently banned because of its link with lung cancer and other types of cancer), cadmium (a type of metal used in metalworking), or organic solvents, especially trichloroethylene.
Being overweight also appears to affect risk, with some experts attributing as many as 20 percent of kidney cancer cases to obesity. Obesity appears to influence certain hormones that may play a role in renal cell cancers. Patients who develop cystic disease (cancerous cysts) while on long-term dialysis (a medical procedure that uses a specially designed machine to filter the blood) are at greater risk for renal cell cancer. The cysts are usually found early, however, and can therefore be removed before they spread.
Overuse of painkillers containing the once popular, over-the-counter analgesic phenacetin has also been associated with renal cell carcinoma. Fortunately, phenacetin was banned by the U.S. Food and Drug Administration in 1983.
As with all cancers, there are certain risk factors for kidney cancer that are out of our control. Increasing age is one example. Kidney cancer is usually diagnosed in people aged 50–70. Another uncontrollable risk factor is gender: Men are twice as likely as women to develop the disease. This may be because men are more likely to smoke (this trend is changing) and are more likely to be exposed to carcinogenic chemicals at the workplace.
In addition, there are hereditary factors that predispose some people to kidney tumors. Certain genetic mutations (defects), such as von Hippel- Lindau syndrome, significantly raise the risk of developing renal cell carcinoma. Finally, people with a disease known as tuberous sclerosis frequently develop cysts in their kidneys, liver, and pancreas and have an elevated risk of getting renal cell cancer.
Can anything be done to prevent kidney cancer?
Although the causes of renal cell carcinoma are not well understood, there are certain steps a person can take to protect him- or herself against the disease. First, do not smoke. Second, avoid long-term workplace exposure to carcinogenic substances, particularly asbestos, cadmium and organic solvents. If you do work with chemicals, make sure you follow occupational safety practices. Third, maintain a healthy weight.
What are the signs and symptoms of kidney cancer?
The most common sign of kidney cancer is blood in the urine, a painless condition called hematuria. This sign of renal cell carcinoma occurs in about 60 percent of patients. Bear in mind, however, that hematuria can also indicate many noncancerous conditions, such as kidney stones, kidney infections or benign tumors.
Other warning signals of kidney cancer include: low back pain; a mass or hard lump in the belly; unexplained weight loss; fatigue; recurrent fevers (not stemming from an infection); persistent pain in the side; swelling of the ankles and legs; low red blood cell counts (anemia); and high blood pressure. These signs and symptoms can also be caused by less serious conditions. However, if you notice any of them, it is important to see your doctor for an evaluation as soon as possible.
Unfortunately, kidney cancer frequently goes undiagnosed (or misdiagnosed) until it has already metastasized (spread). Because so many people over age 40 suffer from back pain, for example, this symptom of kidney cancer is often ignored. At the time of diagnosis, 15–25 percent of people with kidney cancer have metastatic disease.
What tests are used to diagnose kidney cancer?
If kidney cancer is suspected, the doctor will use several methods to diagnose the disease. First, the doctor will question the patient about his or her medical history and perform a physical exam, which will include feeling the abdomen for irregular masses. A urine sample will likely betaken and sent to a laboratory to detect small amounts of blood not visible to the naked eye or to rule out an infection. The doctor may also order another urine test called cytology, in which urine cells are examined under a microscope to find actual cancerous cells.
Blood tests to detect conditions sometimes associated with kidney cancer may also be ordered. These conditions include anemia (too few red blood cells), polycythemia (too many red blood cells due to the production by some types of kidney tumors of a hormone that steps up red blood cell production by the bone marrow), and hypercalcemia (high blood calcium levels).
One or more imaging tests to produce pictures of the kidneys and surrounding organs may also be performed. These tests may include: ultrasonography (ultrasound), which uses sound waves to generate images of the targeted area; computed tomography (CT scan), which is a specialized x-ray procedure in which x-rays are put together by a computer to create detailed cross-sectional images of the body; and magnetic resonance imaging (MRI), in which images are produced using strong magnets and radio waves instead of x-rays.
In addition, intravenous pyelography (IVP) may be done to help determine the extent of the damage to the kidney caused by a tumor. IVP is a procedure in which a series of x-rays are taken after a special dye is injected into the bloodstream. The dye travels in the blood to the kidneys, where it outlines the kidneys and nearby organs, such as the ureters and bladder, giving the doctor a clearer picture of the areas potentially affected by cancer.
Another common imaging test is arteriography, an x-ray procedure for examining blood vessels. Like IVP, it uses a contrast dye, but the dye is injected directly into the artery that supplies blood to the kidney. Arteriography can highlight the blood vessels that feed a kidney tumor, allowing doctors to develop a more precise surgical strategy to remove the tumor.
Once kidney cancer is diagnosed, imaging tests are performed to determine the extent of the disease. This is called staging. The stage of a cancer is the most significant factor when devising a treatment plan. In addition to the imaging studies described above, imaging tests that help doctors determine how far the cancer has spread include chest x-rays to check if the cancer has spread to the lungs and bone scans to check whether the cancer has spread to the bones.
What are the stages of kidney cancer?
For renal cell carcinoma, there are two staging systems that can be used to describe the extent of the disease: the TNM system (also known as the American Joint Committee on Cancer, or AJCC, system) and the Robson Staging System. Both classify the cancer using Roman numerals from I through IV (1–4). The higher the stage number, the more the cancer has spread and the more serious the disease.
The TNM system is used far more often than Robson classification. It is based on three main variables. The “T,” which stands for tumor, is followed by a number ranging from 1 to 3, and this indicates the tumor size and the extent by which the tumor has invaded nearby tissues. (Higher T numbers mean a bigger tumor or more extensive spread into surrounding tissues.)
The “N,” which is followed by a number from 0 to 2, indicates whether the cancer has spread to nearby lymph nodes (small collections of immune system cells that help fight infections) and how many lymph nodes contain cancer. And the “M,” followed by a 0 or 1, tells whether the cancer has spread to distant organs in the body or to lymph nodes not located near the kidney.
How is kidney cancer treated?
Treatment of kidney cancer depends on the type of tumor and the stage of the disease, as well as the patient’s age and overall health.
Surgery is the primary form of treatment for kidney cancer.Most often, a procedure known as radical nephrectomy is done. Radical nephrectomy involves removal of the entire kidney, as well as the adrenal gland (a gland that rests on the upper end of each kidney) and some surrounding fatty tissue and nearby lymph nodes.
Can a person live with only one kidney?
Yes. Despite the fact that the kidneys are extremely important, our bodies only need less than one complete kidney to survive.Today, thousands of Americans are living healthy lives with just one kidney. Some people have no working kidneys, but even they can survive with the aid of dialysis (a specially designed process to filter the blood).
Another type of surgery, partial nephrectomy, is used to treat smaller renal cell tumors. This technique involves removal of only the part of the kidney that contains the cancer. It is used in patients who have cancer in both kidneys, have only one kidney, or have a very small tumor.
Sometimes a procedure known as arterial embolization, which blocks the artery that feeds blood to the kidney (renal artery), is performed before surgery. A catheter (thin tube) is inserted into an artery in the groin and threaded through the blood vessel until it reaches the renal artery. Small pieces of a special gelatin sponge are then injected through the catheter to clog the renal artery. The goal is to kill some of the cancer cells and to reduce bleeding during the operation. In patients who cannot have surgery, arterial embolization may be used as a form of therapy.
Radiation therapy, in which high-energy rays are used to kill cancer cells, may also be used to treat kidney cancer, either before surgery to shrink the tumor or after surgery to destroy any remaining cancer cells. For advanced cancer, radiation therapy may also be used to relieve symptoms of pain or bleeding. In addition, radiation is sometimes used as the main form of therapy in patients whose overall health is too fragile to undergo surgery.
The type of radiation therapy used in treating kidney cancer is external beam radiation therapy, which means the radiation is administered from a machine, and the procedure is a lot like having an x-ray.
Although radiation is useful in treating many types of cancers, renal cell carcinomas do not respond particularly well to the therapy. So, although radiation therapy is a treatment option for kidney cancer, it is not routinely recommended.
Chemotherapy, the use of cancer-killing drugs, is sometimes given in addition to surgery for kidney cancer. But, like radiation therapy, chemotherapy is not very effective in treating renal cell carcinoma. Researchers are currently studying new anti-cancer drugs and new drug combinations to improve chemotherapy’s effectiveness.
Immunotherapy, also called biological therapy, is the newest form of treatment for kidney cancer. In recent years, it has become a standard treatment for metastatic renal cell cancer. Immunotherapy is a method of inducing the body’s own natural immune defenses to fight cancer. For metastatic renal cell cancer, it involves administering drugs called cytokines, which are proteins that stimulate the immune system. The two cytokines used most often are interleukin-2 (IL-2) and interferon-alpha. Studies have shown that both of these cytokines cause renal cell cancers to shrink by more than 50 percent in about 20 percent of patients. New research also suggests that combining IL-2, interferon and chemotherapy is promising.
Esophageal Cancer
About Esophageal Cancer
The esophagus is the hollow tube that connects the throat to the stomach. When a person swallows, the muscular wall of the esophagus contracts to push food and liquid down into the stomach for digestion.To make swallowing easier, glands located in the lining of the esophagus produce mucus, which keeps the pathway moist.
The wall of the esophagus is made up of several layers. Cancer of the esophagus, called esophageal cancer, originates in the inner layer, growing outward.
In the United States, approximately 13,200 people (9,900 men and 3,300 women) will be diagnosed with esophageal cancer during 2001, according to estimates by the American Cancer Society. About 12,500 people (9,500 men and 3,000 women) will die from the disease in 2001.The reason such a high percentage of people with esophageal cancer eventually die from the disease is that the cancer is usually only discovered at an advanced stage.
What are the different types of esophageal cancer?
There are two major types of cancer of the esophagus, squamous cell carcinoma and adenocarcinoma.
The top layer of the lining of the entire length of the esophagus is made up of squamous cells, so squamous cell carcinoma can begin anywhere in the organ. Adenocarcinoma, on the other hand, starts only in the lower part of the esophagus, near the opening of the stomach, where glandular tissue is present. Prior to adenocarcinoma developing, the squamous cells near the opening of the stomach must be altered by acid reflux, as in Barrett’s esophagus [see below].
What are the risk factors for esophageal cancer?
Studies indicate that the following factors raise the risk of developing esophageal cancer:
Tobacco use: Using any kind of tobacco — cigarettes, cigars, pipes or chewing tobacco — is a major risk factor for esophageal cancer.
Alcohol use: Chronic, heavy drinking is another major risk factor for cancer of the esophagus. In people who both drink and smoke, the risk of cancer is especially high. For example, risk increases by 18 times in people who drink more than 13 ounces of alcohol a day for several years. If these same people smoke at least 1–2 packs of cigarettes a day, the risk of esophageal cancer multiplies 44 times.
Barrett’s esophagus: This is a condition characterized by chronic reflux (backward flow) of acidic fluid from the stomach into the lower esophagus. Some people with Barrett’s esophagus experience heartburn from the reflux, but others experience no symptoms and are unaware that they have the condition.Whether or not Barrett’s esophagus has been diagnosed, long-term gastric reflux is a risk factor for adenocarcinoma of the esophagus, because the reflux alters the esophageal cells located near the opening of the stomach.The abnormal cells can develop precancerous changes known as dysplasia, making people with Barrett’s esophagus about 50 times more likely to develop cancer of the esophagus compared to people without the condition. Specifically, about one out of every 100 people with Barrett’s esophagus develops esophageal cancer per year.
Irritation or damage to the esophagus: Besides chronic gastric reflux, other causes of irritation or damage to the esophagus also pose a risk for esophageal cancer. Ingestion of lye — a chemical found in strong household cleaners, such as drain cleaners — can burn esophageal cells. If a child accidentally drinks a cleaning liquid containing lye, the lining of the esophagus will scar, and the child will have a higher risk of squamous cell esophageal cancer.
Diet: A diet deficient in fruits, vegetables, and certain vitamins and minerals, especially vitamins A, C, riboflavin and the mineral selenium, may raise the risk of cancer.Obesity has also been associated with elevated risk.
A history of certain diseases: Three rare conditions — achalasia, esophageal webs and tylosis — raise the likelihood of developing esophageal cancer.
In achalasia, the muscle at the bottom of the esophagus does not relax enough to release food into the stomach. As a result, food collects there, expanding the esophagus and raising the risk of squamous cell carcinoma. Esophageal webs are abnormal pieces of tissue that extend into the esophagus and can make it difficult to swallow. People who have esophageal webs often have problems with the tongue, fingernails, spleen and other organs, a combination of difficulties usually called Plummer- Vinson syndrome but also sometimes called Paterson-Kelly syndrome.
Tylosis is characterized by excess skin growing on the palms of the hands and soles of the feet. For unknown reasons, people with tylosis are very likely to get esophageal cancer and should therefore be screened regularly.
Risk factors for esophageal cancer that we cannot control include age, gender, and race.The cancer is more likely to strike as we age, with a majority of patients developing the disease between the ages of 45 and 70. The disease is also more common in males, afflicting three times more men than women. African Americans are almost three times more likely than whites to be affected.
Can anything be done to prevent esophageal cancer?
Avoiding tobacco use and limiting alcohol consumption are the best strategies for preventing esophageal cancer.
If you suffer from heartburn, talk to your doctor about treating it. There are a number of medications available for preventing gastric reflux.There are also several lifestyle modifications that can help prevent reflux, such as avoiding acidic foods (such as citrus fruits and tomatoes), spicy foods or fatty foods, and avoiding bending over, lying down, or exercising soon after meals.
Because obesity and poor diet have also been tied to esophageal cancer, maintaining a healthy weight and eating more fruits and vegetables may also reduce the risk of the disease. In addition, early studies suggest that taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) may help lower the risk of cancer of the esophagus. However, it is too soon to recommend taking aspirin or NSAIDs exclusively for this purpose.
Is there a screening test for esophageal cancer?
There is no routine screening test for the general population. However, there is an early-detection test available for high-risk people, such as individuals with a history of Barrett’s esophagus. The test is an endoscopy, which involves examining the esophagus through a flexible lighted tube called an endoscope. During an endoscopic examination, the doctor can remove a sample of tissue to examine under a microscope for the presence of cancerous cells.This is called a biopsy.
For people with Barrett’s esophagus, endoscopy and biopsies are recommended every 1–3 years, depending on the degree of dysplasia (cell abnormalities) found on the first endoscopic biopsy test. If no dysplasia is found, many doctors recommend endoscopy and biopsies every 2 – 3 years. If low-grade (less severe) dysplasia is present, screening is usually repeated once a year. However, for high-grade (more severe) dysplasia, surgery to remove the area of Barrett’s esophagus is usually recommended.
This is because there is a high likelihood that cancer is already present (even if it is not detected by endoscopy) or will develop soon.
What are the signs and symptoms of esophageal cancer?
Unfortunately, the signs and symptoms of esophageal cancer do not become apparent until the disease has progressed to a late stage. The most common symptom is difficulty swallowing, medically known as dysphagia. (To cause this symptom, a tumor must be large enough to block about half the diameter of the esophagus.) About 50 percent of patients also experience weight loss due to the inability to swallow enough food to maintain their weight. Sometimes, patients experience pain or a burning sensation in the mid-chest region. In people with advanced esophageal cancer, signs and symptoms may also include hoarseness, chronic cough, hiccups, vomiting, pneumonia and high calcium levels in the blood.
If you experience any of these symptoms, contact your physician. The symptoms can be caused by conditions other than cancer, but it is important to see your doctor for an examination.
What tests are used to diagnose esophageal cancer?
If esophageal cancer is suspected, the doctor will use several methods to diagnose the disease beginning with a medical interview to look for risk factors and symptoms, and a physical exam.
The doctor will also order diagnostic tests, starting with a barium swallow. This is a series of upper GI (gastrointestinal) x-rays taken after the patient drinks a liquid containing barium, which coats the inside of the esophagus and shows up on the images to highlight any abnormalities. To further enhance the clarity of a barium swallow, the doctor can do a double-contrast study, in which air is blown into the esophagus to help push the barium toward the esophageal wall, allowing it to better coat the surface.
Another diagnostic test is an endoscopy – see above,“Is there a screening test for esophageal cancer?”
Once esophageal cancer is diagnosed, more tests will be performed to determine the extent of the disease. This is called staging. These tests not only produce images of the esophagus but also of the surrounding organs and nearby lymph nodes (small collections of immune system cells that help fight infections). One such test is a computed tomography scan (CT scan) – a specialized procedure in which a series of x-rays taken at different angles are put together by a computer to create detailed crosssectional images of the body. A second, newer procedure is endoscopic ultrasound in which an ultrasound probe uses sound waves to generate images of the targeted area.
Another staging test is a bronchoscopy – a procedure in which the doctor inserts a bronchoscope (a thin, flexible, lighted tube similar to an endoscope) into the mouth and down through the windpipe (trachea) to determine if cancer has spread to the tubes connecting the trachea to the lungs (the bronchi). If the doctor needs to examine the lymph nodes in the chest and abdomen for signs of cancer, further tests can be done.
What are the stages of esophageal cancer?
The stage of a cancer is the most significant factor when devising a treatment plan. For esophageal cancer, the system usually used to stage the disease is the TNM system (also known as the American Joint Committee on Cancer, or AJCC, system).This system is based on three main variables: “T,” which refers to the size of the tumor;“N,” which describes how far the cancer has spread to nearby lymph nodes; and “M,” which indicates whether the cancer has spread to distant organs in the body or to lymph nodes not located near the esophagus.
The TNM system is used to categorize the cancer in stages 0 through IV (0–4).The higher the stage number, the more the cancer has spread. Some doctors also divide the stages into letters (for example, IIA or IIB) to further clarify the extent of the cancer.
How is esophageal cancer treated?
Treatment of esophageal cancer depends on the type of tumor and the stage of the disease, the condition of the esophagus, and the patient’s age and overall health.The three main treatment methods include surgery, chemotherapy and radiation therapy. A new treatment, photodynamic therapy, is also an option for some patients. Frequently, a combination of treatments is recommended.
The goal of surgery is to remove the cancer and a margin of cancer-free surrounding tissue. Unfortunately, surgery is a cure for esophageal cancer in less than 25 percent of cases. However, it is frequently used to relieve symptoms, particularly dysphagia (difficulty swallowing). Surgery successfully alleviates dysphagia in more than 80 percent of patients.
The two most common surgical procedures are esophagectomy and esophagogastrectomy. In an esophagectomy, the surgeon removes part of the esophagus and nearby lymph nodes, then reconnects the remainder of the esophagus to the stomach. In an esophagogastrectomy, which is used for more severe cancer, the surgeon removes part of the esophagus, nearby lymph nodes, and the upper part of the stomach.The remainder of the stomach is then connected to the upper part of the esophagus.These surgical procedures are often complicated by the need to remove a large part of the esophagus. If this is the case, there are two methods used to reconnect the remaining portion of the esophagus and stomach. In the first, the stomach is simply brought up to esophagus and ends up being located in the upper part of the chest. In the second, a portion of the large intestine is removed and used to replace the missing part of the esophagus.
If chemotherapy (the use of cancer-killing drugs) is recommended, it can be administered by injection into a vein (IV) or by mouth.The drugs enter the bloodstream and travel throughout the whole body, attacking cancer cells found beyond the esophagus.A combination of anticancer drugs is usually used, typically given in cycles (a period of treatment followed by a period of recovery, then another treatment period, and so on). Chemotherapy may be used in three ways. First, it can be given before surgery to shrink the tumor and thereby enable a more complete surgical removal of the cancer. Second, it can be used in combination with radiation therapy in patients who cannot undergo surgery. Third, it can be used to relieve symptoms (called palliative therapy) in late-stage esophageal cancer.
Radiation therapy, in which high-energy rays are used to kill cancer cells, is also used to treat esophageal cancer, usually in combination with surgery and/or chemotherapy. For example, radiation may be administered either before surgery to shrink the tumor or after surgery to destroy any remaining cancer cells. For advanced cancer, radiation therapy may be used to relieve symptoms, particularly dysphagia. In a patient whose overall health is too fragile to undergo surgery, radiation is sometimes used by itself as the main form of therapy.
The most common type of radiation therapy used for esophageal cancer is external beam radiation therapy, which means the radiation is administered from a machine, and the procedure is a lot like having an x-ray. Occasionally, internal radiation therapy (brachytherapy), in which radioactive material is implanted in the esophagus near the cancer, is used. The final treatment option is photodynamic therapy. It involves the injection of a nontoxic chemical into the bloodstream, where it is allowed to circulate and collect in the tumor for a few days.A special laser is then focused on the tumor through an endoscope.The intense light of the laser alters the chemical, transforming it into a toxic drug that can kill cancer cells. More research is needed on photodynamic therapy, but it represents a promising new therapeutic option.
Chemotherapy
About Chemotherapy
Surgery and radiation therapy are very effective at controlling cancers that have not spread beyond their site of origin. But the toughest challenge in the fight against cancer is to destroy tumor cells that have strayed to other parts of the body.
Oncologists use systemic (system-wide) therapy, which travels throughout the entire body via the bloodstream, to keep these rogue cancer cells in check. There are two main kinds of systemic therapy: chemotherapy and hormone therapy. Chemotherapy involves the use of toxic drugs to kill tumor cells. (Hormone therapy blocks hormones that fuel the growth of certain cancers.)
Normal cells grow and divide in a controlled way; but when cancer develops, cells begin to divide rapidly, without control. Chemotherapy drugs, commonly referred to as anticancer drugs, are designed to kill or disable rapidly dividing cells. Many of these drugs act on human cells much like some antibiotics act on bacteria: They prevent the replication of DNA, a critical step in cell division, thereby preventing the cells from multiplying. Other anticancer drugs interfere with enzymes produced by tumor cells that help them to grow. The most effective treatment involvestwo or more anticancer agents to tackle unrestrained cell division from several angles. This is called combination chemotherapy.
Adjuvant means “in addition to,” and in cancer treatment it refers to treatments used in addition to the primary treatments of surgery and radiation. Chemotherapy is usually an adjuvant therapy. Sometimes, however, it is used to shrink a tumor before surgery or radiation therapy and makes it easier to remove or destroy the cancerous mass. This is called neoadjuvant chemotherapy. Chemotherapy can also be used to shrink a tumor in order to alleviate symptoms it may be causing, such as back pain.
Many different drugs are currently in use as chemotherapy agents, and new ones are constantly being developed and tested.
Drug delivery and scheduling
Chemotherapy may be administered in a hospital’s outpatient or inpatient department, a doctor’s office, a clinic, or even at home. The choice of location depends on which drugs are used, a patient’s health insurance, and the doctor’s preferences. Most patients receive their treatment in a hospital’s outpatient department, which cares for patients who do not need to stay overnight. Though some anticancer drugs can be taken orally or through an injection, most require intravenous (IV, through a vein) administration.
Chemotherapy is often given in cycles; for example, two weeks of therapy followed by two weeks without therapy, over a period of several months. Cancer cells do not all divide at the same time, and staggering treatments can capture different populations of cells in the midst of growing and dividing, when they are most vulnerable to the chemotherapy drugs. Staggering, or “cycling,” also provides rest periods to give healthy cells a chance to recover.
The schedule on which chemotherapy is administered is based on years of research. Some drugs are given daily; some are given weekly for several months; and some are given once a month for many months. Schedules often differ from patient to patient, as they are tailored to the individual’s circumstances.
Side effects
The disadvantage of chemotherapy is that healthy cells can also be harmed by anticancer drugs, especially those cells that normally divide quickly. These include cells in the hair follicles, bone marrow, and lining of the gastrointestinal tract. The result can be hair loss; depressed red and white blood cell counts, causing anemia and an inability to fight off infections, respectively; and nausea, vomiting and mouth sores. Chemotherapy can also have several neurological side effects, such as fuzzy thinking and difficulty concentrating.
Though chemotherapy can cause these distressing side effects, nowadays treatments are much easier to tolerate. Doctors have a clearer understanding of how the drugs work, and dosages are more precisely calibrated to reduce the side effects. In addition, new anti-nausea medications can prevent nausea and vomiting in many patients and significantly reduce its severity in others. Indeed, the perception of chemotherapy as being “worse than the cancer itself” no longer holds true.
Cervical cancer
About Cervical cancer
The cervix is the lower, narrow part of the uterus (womb). It forms a canal that connects the body of the uterus to the vagina.
Cervical cancer originates in the lining of the cervix. The cancer does not form suddenly; rather, it takes years to develop. The process begins when abnormal (but not cancerous) cells slowly grow and spread more deeply into the cervix. This precancerous overgrowth of cells is called cervical dysplasia. Scientists believe that dysplasia is the first step in a slow process that can eventually lead to cancer.
Fifty years ago, cervical cancer was the leading cause of cancer death among American women. But thanks to the development of the Pap smear test – named after George Papanicolaou, who introduced the test in 1943 – the death rate from cervical cancer has since dropped by 74 percent.
Cervical cancer still remains a serious health concern, however. According to the estimates of the American Cancer Society and the National Cancer Institute, 12,800 new cases of cervical cancer were diagnosed in the United States in the year 2000, and 4,600 women died from the disease.
What are the risk factors for cervical cancer?
The risk factor that far outweighs all others is infection with the human papilloma virus (HPV), which is sexually transmitted. HPV is actually a family of over 75 viruses, 13 of which are known to cause cervical cancer. Infection is extremely common, but many women never know they have HPV because the virus does not always produce symptoms. When it does, the main symptom is genital warts. Overall, HPV has been associated with 82 percent of all cases of cervical cancer.
Other risks for cervical cancer include factors that increase a woman’s risk of getting HPV, including: engaging in sexual intercourse starting at an early age; having multiple sexual partners; having sexual intercourse with someone who has had multiple partners; and having other sexually transmitted diseases, such as chlamydia or herpes.
Not having an annual pelvic exam with a Pap smear test is another major risk factor for cancer of the cervix. Fifty percent of all women who get invasive cervical cancer have never had a Pap smear, and 40 percent have not had one within five years of their diagnosis. Many health-care professionals recommend that all women have yearly Pap tests starting at age 18 or when they start having sexual intercourse.
Increasing age and smoking are also risk factors for cervical cancer (as they are with all cancers). In addition, certain minorities have higher cervical cancer death rates, including African Americans, Hispanics and Native Americans. Poor women are at greater risk for the disease, most likely because they cannot afford to get regular Pap tests.
Finally, infection with HIV (the virus that causes AIDS) is a risk factor for cervical cancer because being HIV-positive weakens a woman’s immune system, making her less able to fight the virus and early cancers.
Can anything be done to prevent cervical cancer?
Yes. Getting a yearly Pap-smear test, which can detect abnormal cells before they progress to cancer, greatly reduces a woman’s risk of cervical cancer. As mentioned above, 90 percent of all women who get invasive cervical cancer have not had a Pap smear within the last five years.
Other precautions women can take include: limiting the number of sexual partners; consistently using condoms to prevent transmission of sexual infections*; and quitting smoking.
*Condoms cannot prevent the spread of HPV, which is transmitted by skin-to-skin contact with any HPV-infected skin in the genital region. However, contracting other sexual infections makes a woman more susceptible to HPV, and condom use can prevent transmission of those infections.
What exactly is a Pap-smear test?
A Pap smear involves taking a sample of cells from the cervix. The doctor uses an instrument called a speculum to open the vagina. He or she then scrapes the surface of the cervix with a cotton swab, a brush, or a small wooden stick. The specimen is placed on a glass slide and sent to a medical laboratory to be examined under a microscope for the presence of infection, inflammation, or cancer.
Abnormal results are found in about 5–10 percent of cases. Most of the time, an abnormal test does not represent cancer but rather irritations or precancerous abnormalities that may correct themselves on their own.
How accurate are Pap-smear tests?
Although the Pap test is currently the best method of preventing and detecting cervical cancer, it is not fail-proof. Errors in both collection and inspection of the cervical smear frequently occur. In fact, false negatives (results that incorrectly indicate that no cancer is present) are relatively common. This is why women need to have a Pap test done annually.
Several new tests have recently been developed to improve the accuracy of Pap smear collection and inspection. One test, ThinPrep, provides a cleaner, clearer picture of cervical cells than the conventional Pap smear. Studies have shown that ThinPrep can reduce the rate of false negatives by as much as 30-40 percent.
Another new test, called Hybrid Capture, can be used in combination with a Pap test to clarify borderline results. The test detects the DNA of HPV. If HPV is found, a woman is considered at much higher risk for cervical cancer and can be closely monitored.
Two other new tests, PAPNET and AutoPap, use computer scanning systems to rescreen any Pap-smear slides deemed normal by lab workers. These tests have not proven to be significantly better than humans at re-examining slides.
What are the symptoms of cervical cancer?
Precancerous changes of the cervix and early cervical cancer generally do not cause any symptoms. This is why it’s so important to have regular pelvic exams and Pap tests. Symptoms do not usually appear until the cancer has spread to nearby tissue. At that point, the most common symptom is abnormal bleeding between regular menstrual periods or after sexual intercourse. Unusual vaginal discharge is another symptom.
What tests are used to confirm a diagnosis of cervical cancer?
If the results of a Pap smear suggest cancer, the following diagnostic tests may be done:
Colposcopy: The doctor examines the cervix through an instrument similar to a microscope, called a colposcope. The doctor may coat the cervix with an iodine solution that turns healthy cells brown and abnormal cells white or yellow (a Schiller test).
Biopsy: The doctor uses one of several methods to remove a sample of tissue for closer examination under a microscope. A biopsy is the only way to know for sure whether cancer is present.
If the biopsy reveals cancer, more tests will be done to find out how far the cancer has spread; for example, a cystoscopy to check if the cancer has spread to the bladder; a proctoscopy to check if the cancer has spread to the rectum; and a chest x-ray to check the lungs for cancer.
What are the stages of cervical cancer?
Stage 0, or “carcinoma in situ,” is the earliest stage of cervical cancer, in which abnormal cells are confined to the first layer of cervical cells and have not migrated to the deeper tissues of the cervix. If detected at Stage 0, the survival rate of cervical cancer is 100 percent.
In Stage I, the cancer has spread within the cervix but has not spread to nearby organs. Survival rates are still excellent at this stage, at about 85-90 percent.
In Stage II, the cancer has spread to nearby areas but is still confined to the pelvic area. Survival rates at this stage are about 60 percent.
Stage III is defined as cancer that has spread throughout the pelvic area and possibly to the lower part of the vagina. Cancerous cells may also have spread to the tubes that connect the kidneys to the bladder (the ureters). Survival rates are approximately 30 percent.
In Stage IV, cancer has spread to other parts of the body, either close to the cervix, such as the bladder or rectum, or to distant organs, such as the lungs. At stage IV, the survival rate is about 10 percent.
How is cervical cancer treated?
Treatment of cervical cancer depends on the stage as well as a woman’s age, overall health, and desire to have children.
To treat Stage 0, a doctor may use one of several types of surgery to either cut out the cancerous tissue or destroy it.
Conization: In this procedure, the doctor removes a cone-shaped piece of tissue where the abnormality is found.
Laser Surgery: A laser is used to destroy the abnormal area without damaging the surrounding healthy tissue.
LEEP: Loop electrosurgical excision procedure (LEEP) uses an electric current passed through a thin wire, which acts as a knife to remove a small piece of tissue.
Cryosurgery (freezing) or Cauterization (burning): This is also common methods of destroying the abnormal tissue.
For Stage I cervical cancer, treatment may involve a simple hysterectomy, in which only the uterus is removed; a radical hysterectomy, in which the uterus, the cervix, and the upper part of the vagina are removed along with lymph nodes from the pelvis (called pelvic lymph node dissection); or radiation therapy (the use of high-energy rays to kill cancer cells).
Stage II cancer can be treated with either radical hysterectomy with pelvic lymph node dissection or radiation therapy. For younger women, surgery may be a better option because it preserves ovarian function; radiation therapy does not. Sometimes chemotherapy (the use of cancer-killing drugs that circulate throughout the entire body) is also used.
For Stage III and Stage IV cervical cancer, treatment involves radiation therapy plus chemotherapy.
When cervical cancer comes back after earlier treatment (recurrent cancer), surgery known as pelvic exenteration may be used. In addition to all the organs and tissues removed in a radical hysterectomy with pelvic lymph node dissection, the bladder, vagina, rectum, and part of the colonmay also be removed.
Friday, November 21, 2008
Circulating Tumor Cells Can Reveal Genetic Signature Of Dangerous Lung Cancers
ScienceDaily (July 4, 2008) — Massachusetts General Hospital (MGH) investigators have shown that an MGH-developed, microchip-based device that detects and analyzes tumor cells in the bloodstream can be used to determine the genetic signature of lung tumors, allowing identification of those appropriate for targeted treatment and monitoring genetic changes that occur during therapy.
A pilot study of the device called the CTC-chip will appear in the July 24 New England Journal of Medicine and is receiving early online release.
"The CTC-chip opens up a whole new field of studying tumors in real time," says Daniel Haber, MD, director of the MGH Cancer Center and the study's senior author. "When the device is ready for larger clinical trials, it should give us new options for measuring treatment response, defining prognostic and predictive measures, and studying the biology of blood-borne metastasis, which is the primary method by which cancer spreads and becomes lethal."
CTCs or circulating tumor cells are living solid-tumor cells found at extremely low levels in the bloodstream. Until the development of the CTC-chip by researchers from the MGH Cancer Center and BioMEMS (BioMicroElectroMechanical Systems) Resource Center, it was not possible to get information from CTCs that would be useful for clinical decision-making. The current study was designed to find whether the device could go beyond detecting CTCs to helping analyze the genetic mutations that can make a tumor sensitive to treatment with targeted therapy drugs.
The researchers tested blood samples from patients with non-small-cell lung cancer (NSCLC), the leading cause of cancer death in the U.S. In 2004, MGH researchers and a team from Dana-Farber Cancer Institute both discovered that mutations in a protein called EGFR determine whether NSCLC tumors respond to a group of drugs called TKIs, which includes Iressa and Tarceva. Although the response of sensitive tumors to those drugs can be swift and dramatic, eventually many tumors become resistant to the drugs and resume growing.
The CTC-chip was used to analyze blood samples from 27 patients -- 23 who had EGFR mutations and 4 who did not -- and CTCs were identified in samples from all patients. Genetic analysis of CTCs from mutation-positive tumors detected those mutations 92 percent of the time. In addition to the primary mutation that leads to initial tumor development and TKI sensitivity, the CTC-chip also detected a secondary mutation associated with treatment resistance in some participants, including those whose tumors originally responded to treatment but later resumed growing.
"Patients found to have resistance mutations before treatment probably won't benefit as much or as long from single-agent TKI therapy as those without such baseline mutations," says Lecia Sequist, MD, MPH, of the MGH Cancer Center, a co-lead author of the NEJM paper. "For those patients we may need to consider other modes of therapy, including combinations+ of targeting agents or second-generation TKIs that can overcome the most common resistance mutation."
Blood samples were taken at regular intervals during the course of treatment from four patients with mutation-positive tumors. In all of those patients, levels of CTCs dropped sharply after TKI treatment began and began rising when tumors resumed growing. In one patient, adding additional chemotherapy caused CTC levels to drop again as the tumor continued shrinking.
Throughout the course of therapy, the tumors' genetic makeup continued to evolve. Not only did the most common resistance mutation emerge in tumors where it was not initially present, but new activating mutations -- the type that causes a tumor to develop in the first place -- appeared in seven patients' tumors, indicating that these cancers are more genetically complex than expected and that continuing to monitor tumor genotype throughout the course of treatment may be crucial.
"If tumor genotypes don't remain static during therapy, it's essential to know exactly what you're treating at the time you are treating it," says Haber. "Biopsy samples taken at the time of diagnosis can never tell us about changes emerging during therapy or genotypic differences that may occur in different sites of the original tumor, but the CTC-chip offers the promise of noninvasive continuous monitoring." Haber is the Kurt J. Isselbacher/Peter D. Schwartz Professor of Medicine at Harvard Medical School.
Additional lead authors of the NEJM paper are Shyamala Maheswaran, PhD, MGH Cancer Center; and Sunitha Nagrath, PhD, MGH BioMEMS Resource Center. Co-authors are Lindsey Ulkus, Brian Brannigan, Elizabeth Inserra, Sven Diederichs PhD, Daphne Bell, PhD, Subba Digumarthy, MD, Alona Muzikansky, MS, Jeffrey Settleman, PhD, and Thomas J. Lynch MD, MGH Cancer Center; Chey Collura, MS, Daniel Irimia, PhD, and Mehmet Tone,r PhD, BioMEMS Resource Center; John Iafrate, MD, PhD, MGH Pathology; and Ronald G. Tompkins MD, ScD, MGH Surgery. The study was supported by grants from the National Institutes of Health; the Doris Duke, Ellison and Monell Foundations; the National Foundation for Cancer Research, and the Howard Hughes Medical Institute.
___
Adapted from materials provided by Massachusetts General Hospital.
Lymphoma
About Lymphoma
Lymphoma is a general term for cancers of the lymphatic system. The lymphatic system is part of the immune system. It consists of a network of vessels and nodes. The vessels carry a watery fluid called lymph, which contains infection-fighting white blood cells, to all parts of the body. Scattered throughout the network of vessels are lymph nodes, where white blood cells are made and stored. Clusters of lymph nodes are found in the underarms, groin, neck, chest and abdomen. The spleen, bone marrow, thymus and tonsils are also parts of the lymphatic system.
Lymphoma develops when white blood cells known as lymphocytes become abnormal and start dividing without control. Because lymphatic tissue is present in many parts of the body, lymphoma can start almost anywhere. It can occur in one lymph node, in a group of nodes, or in an organ. It can then spread to almost any area of the body.
Hodgkin’s disease is one type of lymphoma, named after Dr. Thomas Hodgkin who first identified the disease in 1832. All other lymphomas are collectively classified as non-Hodgkin’s lymphoma. Hodgkin’s disease and non-Hodgkin’s lymphoma are distinguished by how the cancer cells look under a microscope. Non-Hodgkin’s lymphoma is far more common.
About 5 percent of all cancers in the United States are lymphomas. According to the American Cancer Society, there were an estimated 54,900 new cases of non-Hodgkin’s lymphoma and 7,400 new cases of Hodgkin’s disease in the United States in the year 2000. Fortunately, lymphomas are a highly curable form of cancer.
What’s the difference between Hodgkin’s disease and non-Hodgkin’s lymphoma?
Although Hodgkin’s disease and non-Hodgkin’s lymphoma are both cancers of the lymphatic system, the malignant cells appear very differently under a microscope and may originate from different subtypes of lymphocytes. (Remember: Lymphocytes are a type of white blood cell.)
Hodgkin’s disease is characterized by a specific type of cell called a Reed-Sternberg cell, which is a large, cancerous lymphocyte with more than one nucleus. There are four types of Hodgkin’s disease, each distinguished by the number of Reed-Sternberg cells relative to the number of other types of white blood cells.
Non-Hodgkin’s lymphomas are more likely to invade the bone marrow, gastrointestinal tract and skin than Hodgkin’s disease. Some types spread very rapidly (over months), and some spread slowly (over years). There are 13 types of non-Hodgkin’s lymphoma. Among them are Burkitt’s lymphoma, which originates from a subtype of lymphocytes known as B lymphocytes, and mycosis fungoides, a lymphoma that originates from cells known as T lymphocytes.
What causes lymphoma?
The cause of lymphoma is unknown, but some experts suspect a virus, most notably the Epstein-Barr virus. HTLV-1 (human T-cell lymphotropic virus type I) has been associated with a very rare type of non-Hodgkin’s lymphoma. (HTLV-1 is a retrovirus similar to HIV [human immunodeficiency virus], which causes AIDS.)
What are the risk factors associated with lymphoma?
Researchers have identified a few factors that may increase a person’s likelihood of getting Hodgkin’s disease or non-Hodgkin’s lymphoma. People who have reduced immune function (for example, those with AIDS or those on immunosuppressive therapy, such as organ transplant patients) are at higher risk. So, too, are people with a history of infection with the Epstein-Barr virus.
For non-Hodgkin’s lymphoma, exposure to radiation and certain chemicals, such as benzene, has also been linked with an increased chance of getting the disease. In addition, genetic disorders that cause children to be born with deficient immune systems raise the risk of developing the cancer.
What are the symptoms of lymphoma?
In Hodgkin’s disease, the first noticeable symptom is usually an enlarged lymph node, most frequently in the neck but sometimes in the groin or underarm area. In non-Hodgkin’s lymphoma, the first symptom is usually several enlarged lymph nodes in either a single area, such as the neck or groin, or throughout the body.
Other symptoms associated with both types of lymphoma include: unexplained fever, weight loss, constant fatigue, night sweats and itchy skin. When lymph nodes inside the chest become swollen, they can place pressure on the windpipe. This can cause symptoms such as coughing and shortness of breath.
Keep in mind that there can be many reasons for these symptoms other than cancer.
How is lymphoma detected?
Lymphoma is most often found when a lump appears in lymph nodes in the neck, underarm or groin. If the nodes remain enlarged for more than a week, especially if other symptoms are present, the doctor may suspect lymphoma. Abnormal blood cell counts and the results of other blood tests and imaging tests may also suggest cancer, but in order to make a definitive diagnosis, a biopsy is necessary.
There are several types of biopsies, and the choice of procedure depends on which node(s) is enlarged and how much tissue is needed for a clear diagnosis. If the enlarged node is close to the surface of the neck, for example, the doctor may perform a needle biopsy, in which a needle and syringe are used to draw out a sample of fluid and small pieces of tissue from the tumor. For an enlarged lymph node deep inside the chest, however, it may be necessary to cut through the skin to remove the entire node or part of a large tumor. Regardless of how the sample is obtained, a pathologist will examine it under a microscope to check for cancer cells.
How is lymphoma staged?
Staging is the process of determining the extent to which a cancer has progressed. The information is used to develop an optimal treatment plan.
For lymphoma, staging is based on how far the cancer has spread (stages I, II, III, and IV) as well as the absence (A) or presence (B) of certain symptoms, such as unexplained fever, weight loss and night sweats. As an example, a cancer may be described as IIIA or IIIB. In general, the higher the number and letter, the more serious the lymphoma.
In addition to stages, non-Hodgkin’s lymphomas are broadly classified into two groups: aggressive (also called high grade or intermediate), which grow quickly and cause severe symptoms, or indolent (also called low grade), which grow slowly and cause fewer symptoms.
To stage lymphoma, the doctor may use some of the same tests used for the diagnosis, including imaging tests, such as a CT scan (computed tomography) or MRI (magnetic resonance imaging), and more extensive lymph node biopsies. In addition, a bone marrow biopsy may be performed. During this procedure, a large needle is used to remove a narrow cylinder of bone and marrow. (Alternatively, the doctor may perform a bone marrow aspiration, in which a smaller needle and syringe are used to draw out a small amount of bone marrow.) The tissue samples are taken from a large bone, usually the back of the hip bone. They are then examined under a microscope to check if cancer cells have invaded the bone marrow. A bone marrow biopsy may only be recommend for patients who have fevers or night sweats or are anemic (have low red blood cell counts), as these are signs that the lymphoma is in the bone marrow.
Lymphoma is a general term for cancers of the lymphatic system. The lymphatic system is part of the immune system. It consists of a network of vessels and nodes. The vessels carry a watery fluid called lymph, which contains infection-fighting white blood cells, to all parts of the body. Scattered throughout the network of vessels are lymph nodes, where white blood cells are made and stored. Clusters of lymph nodes are found in the underarms, groin, neck, chest and abdomen. The spleen, bone marrow, thymus and tonsils are also parts of the lymphatic system.
Lymphoma develops when white blood cells known as lymphocytes become abnormal and start dividing without control. Because lymphatic tissue is present in many parts of the body, lymphoma can start almost anywhere. It can occur in one lymph node, in a group of nodes, or in an organ. It can then spread to almost any area of the body.
Hodgkin’s disease is one type of lymphoma, named after Dr. Thomas Hodgkin who first identified the disease in 1832. All other lymphomas are collectively classified as non-Hodgkin’s lymphoma. Hodgkin’s disease and non-Hodgkin’s lymphoma are distinguished by how the cancer cells look under a microscope. Non-Hodgkin’s lymphoma is far more common.
About 5 percent of all cancers in the United States are lymphomas. According to the American Cancer Society, there were an estimated 54,900 new cases of non-Hodgkin’s lymphoma and 7,400 new cases of Hodgkin’s disease in the United States in the year 2000. Fortunately, lymphomas are a highly curable form of cancer.
What’s the difference between Hodgkin’s disease and non-Hodgkin’s lymphoma?
Although Hodgkin’s disease and non-Hodgkin’s lymphoma are both cancers of the lymphatic system, the malignant cells appear very differently under a microscope and may originate from different subtypes of lymphocytes. (Remember: Lymphocytes are a type of white blood cell.)
Hodgkin’s disease is characterized by a specific type of cell called a Reed-Sternberg cell, which is a large, cancerous lymphocyte with more than one nucleus. There are four types of Hodgkin’s disease, each distinguished by the number of Reed-Sternberg cells relative to the number of other types of white blood cells.
Non-Hodgkin’s lymphomas are more likely to invade the bone marrow, gastrointestinal tract and skin than Hodgkin’s disease. Some types spread very rapidly (over months), and some spread slowly (over years). There are 13 types of non-Hodgkin’s lymphoma. Among them are Burkitt’s lymphoma, which originates from a subtype of lymphocytes known as B lymphocytes, and mycosis fungoides, a lymphoma that originates from cells known as T lymphocytes.
What causes lymphoma?
The cause of lymphoma is unknown, but some experts suspect a virus, most notably the Epstein-Barr virus. HTLV-1 (human T-cell lymphotropic virus type I) has been associated with a very rare type of non-Hodgkin’s lymphoma. (HTLV-1 is a retrovirus similar to HIV [human immunodeficiency virus], which causes AIDS.)
What are the risk factors associated with lymphoma?
Researchers have identified a few factors that may increase a person’s likelihood of getting Hodgkin’s disease or non-Hodgkin’s lymphoma. People who have reduced immune function (for example, those with AIDS or those on immunosuppressive therapy, such as organ transplant patients) are at higher risk. So, too, are people with a history of infection with the Epstein-Barr virus.
For non-Hodgkin’s lymphoma, exposure to radiation and certain chemicals, such as benzene, has also been linked with an increased chance of getting the disease. In addition, genetic disorders that cause children to be born with deficient immune systems raise the risk of developing the cancer.
What are the symptoms of lymphoma?
In Hodgkin’s disease, the first noticeable symptom is usually an enlarged lymph node, most frequently in the neck but sometimes in the groin or underarm area. In non-Hodgkin’s lymphoma, the first symptom is usually several enlarged lymph nodes in either a single area, such as the neck or groin, or throughout the body.
Other symptoms associated with both types of lymphoma include: unexplained fever, weight loss, constant fatigue, night sweats and itchy skin. When lymph nodes inside the chest become swollen, they can place pressure on the windpipe. This can cause symptoms such as coughing and shortness of breath.
Keep in mind that there can be many reasons for these symptoms other than cancer.
How is lymphoma detected?
Lymphoma is most often found when a lump appears in lymph nodes in the neck, underarm or groin. If the nodes remain enlarged for more than a week, especially if other symptoms are present, the doctor may suspect lymphoma. Abnormal blood cell counts and the results of other blood tests and imaging tests may also suggest cancer, but in order to make a definitive diagnosis, a biopsy is necessary.
There are several types of biopsies, and the choice of procedure depends on which node(s) is enlarged and how much tissue is needed for a clear diagnosis. If the enlarged node is close to the surface of the neck, for example, the doctor may perform a needle biopsy, in which a needle and syringe are used to draw out a sample of fluid and small pieces of tissue from the tumor. For an enlarged lymph node deep inside the chest, however, it may be necessary to cut through the skin to remove the entire node or part of a large tumor. Regardless of how the sample is obtained, a pathologist will examine it under a microscope to check for cancer cells.
How is lymphoma staged?
Staging is the process of determining the extent to which a cancer has progressed. The information is used to develop an optimal treatment plan.
For lymphoma, staging is based on how far the cancer has spread (stages I, II, III, and IV) as well as the absence (A) or presence (B) of certain symptoms, such as unexplained fever, weight loss and night sweats. As an example, a cancer may be described as IIIA or IIIB. In general, the higher the number and letter, the more serious the lymphoma.
In addition to stages, non-Hodgkin’s lymphomas are broadly classified into two groups: aggressive (also called high grade or intermediate), which grow quickly and cause severe symptoms, or indolent (also called low grade), which grow slowly and cause fewer symptoms.
To stage lymphoma, the doctor may use some of the same tests used for the diagnosis, including imaging tests, such as a CT scan (computed tomography) or MRI (magnetic resonance imaging), and more extensive lymph node biopsies. In addition, a bone marrow biopsy may be performed. During this procedure, a large needle is used to remove a narrow cylinder of bone and marrow. (Alternatively, the doctor may perform a bone marrow aspiration, in which a smaller needle and syringe are used to draw out a small amount of bone marrow.) The tissue samples are taken from a large bone, usually the back of the hip bone. They are then examined under a microscope to check if cancer cells have invaded the bone marrow. A bone marrow biopsy may only be recommend for patients who have fevers or night sweats or are anemic (have low red blood cell counts), as these are signs that the lymphoma is in the bone marrow.
How is lymphoma treated?
Individual treatment plans for lymphoma depend on the type of lymphoma, how far the cancer has spread, whether it’s aggressive or indolent, and the age and overall health of the patient. Thanks to traditional chemotherapy and newer treatment methods, lymphomas have a relatively high cure rate.
Hodgkin’s disease: For Hodgkin’s disease, chemotherapy and radiation therapy are the main treatment methods.With either one or both of these therapies, about 90 percent of patients with early-stage Hodgkin’s disease are cured. Patients with advanced-stage disease are treated with various combinations of chemotherapy drugs. About two-thirds of these patients are cured.
For patients who stop responding to standard therapy, bone marrow stem-cell transplantation is an option. This complex therapy provides doctors with a way to use very high doses of chemotherapy for more effective treatment. It involves harvesting stem cells (primitive blood cells) from the patient’s bone marrow or the blood stream through a process called apheresis. After the stem cells have been removed and stored, the patient is given extremely high doses of chemotherapy that destroy the bone marrow. The stored stem cells are then returned the patient as a blood transfusion. If successful, it takes several weeks after the stem cells are reinfused for the cells to mature and start making new blood cells.
Non-Hodgkin’s lymphoma: The success of treatment for non-Hodgkin’s lymphoma depends on whether the disease is aggressive or indolent. Aggressive lymphomas have the fastest-growing cancer cells, which means the cells are most vulnerable to the cancer-killing effects of chemotherapy and radiation. While indolent lymphomas do usually respond to chemotherapy and radiation, they are less likely to be completely cured by these treatments, and recurrences are common.
Because aggressive lymphomas grow very rapidly, some types can be life-threatening within months if left untreated. However, if an aggressive lymphoma is diagnosed at Stage I, the chance for a cure is about 80 to 90 percent, and even some of the most advanced cases have a 30 percent chance of a cure.
Usually a combination of several chemotherapy drugs combined with radiation therapy is used for Stage I. Chemotherapy alone is used for all other stages. If the cancer recurs, different chemotherapy drugs are used. Bone marrow transplantation is another option.
Indolent lymphomas may take as long as seven to 10 years before causing any problems. As a result, treatment is not always started immediately. Instead, the doctor may take a “watchful waiting” approach, and chemotherapy and/or radiation therapy are started once symptoms appear.
In some cases, indolent lymphomas are treated from the outset with radiation or chemotherapy, whether or not symptoms are present. The lymphoma often goes into remission, but it may recur many years later as an indolent form or as one of the aggressive kinds. In either case, chemotherapy is used again to treat the cancer. (Occasionally, radiation therapy is also used again, but not to treat the same area of the body.)
In addition to chemotherapy and radiation for treating non-Hodgkin’s lymphoma, a biological therapy called rituximab (Rituxan) is now available. Rituxan, a drug approved by the Food and Drug Administration in 1997 for the treatment of certain indolent lymphomas, is a monoclonal antibody. Monoclonal antibodies, which are genetically engineered in a laboratory, are designed to attach to certain substances on the surface of cancer cells. (Rituxan attaches to a substance called CD20, which is found on some types of indolent non-Hodgkin’s lymphoma cells.) The patient’s body recognizes the monoclonal antibody as an invader, and the immune system kills the cells to which it is attached.
Presently, chemotherapy and radiation therapy are the first treatments given for non-Hodgkin’s lymphoma, and Rituxan is used if these fail or cancer comes back after a remission. However, in the future, Rituxan may become the first line of therapy, depending on the results of research currently under way.
Another biological therapy is interferon. Interferon is a protein naturally produced by white blood cells to help the immune system fight infections. Some research has suggested that interferon can help shrink the tumors of certain types of non-Hodgkin’s lymphoma. It is still not clear, however, which patients are appropriate candidates for interferon therapy and whether it should be given to these patients in addition to chemotherapy.
Although indolent lymphomas are less responsive to treatment than aggressive varieties, this does not mean that the prognosis for indolent cancers is necessarily poor. In fact, indolent lymphomas can progress so slowly that treatment, although it may not cure the disease, can often prolong life to the point where an older adult lives a normal lifespan and dies from another cause.
Is there a lymphoma vaccine under development?
Yes. But, unlike conventional vaccines, the lymphoma vaccine is not intended to prevent lymphoma in healthy people. Rather, it is given to patients in remission from an indolent lymphoma to strengthen the body’s natural defenses to prevent a relapse. The vaccine contains a tiny amount of protein taken from the patient’s own tumor. This allows the body to detect the tumor protein and produce defenses against it, priming the immune system to be ready to destroy any cells it encounters that contain the tumor protein. In a study of 20 patients who were vaccinated, 18 remained in complete remission four years after the therapy began. A larger trial is now under way; however, it could take eight years to produce results.
The lymphoma vaccine will be an exciting addition to the therapeutic arsenal for fighting lymphomas.
Hodgkin’s disease: For Hodgkin’s disease, chemotherapy and radiation therapy are the main treatment methods.With either one or both of these therapies, about 90 percent of patients with early-stage Hodgkin’s disease are cured. Patients with advanced-stage disease are treated with various combinations of chemotherapy drugs. About two-thirds of these patients are cured.
For patients who stop responding to standard therapy, bone marrow stem-cell transplantation is an option. This complex therapy provides doctors with a way to use very high doses of chemotherapy for more effective treatment. It involves harvesting stem cells (primitive blood cells) from the patient’s bone marrow or the blood stream through a process called apheresis. After the stem cells have been removed and stored, the patient is given extremely high doses of chemotherapy that destroy the bone marrow. The stored stem cells are then returned the patient as a blood transfusion. If successful, it takes several weeks after the stem cells are reinfused for the cells to mature and start making new blood cells.
Non-Hodgkin’s lymphoma: The success of treatment for non-Hodgkin’s lymphoma depends on whether the disease is aggressive or indolent. Aggressive lymphomas have the fastest-growing cancer cells, which means the cells are most vulnerable to the cancer-killing effects of chemotherapy and radiation. While indolent lymphomas do usually respond to chemotherapy and radiation, they are less likely to be completely cured by these treatments, and recurrences are common.
Because aggressive lymphomas grow very rapidly, some types can be life-threatening within months if left untreated. However, if an aggressive lymphoma is diagnosed at Stage I, the chance for a cure is about 80 to 90 percent, and even some of the most advanced cases have a 30 percent chance of a cure.
Usually a combination of several chemotherapy drugs combined with radiation therapy is used for Stage I. Chemotherapy alone is used for all other stages. If the cancer recurs, different chemotherapy drugs are used. Bone marrow transplantation is another option.
Indolent lymphomas may take as long as seven to 10 years before causing any problems. As a result, treatment is not always started immediately. Instead, the doctor may take a “watchful waiting” approach, and chemotherapy and/or radiation therapy are started once symptoms appear.
In some cases, indolent lymphomas are treated from the outset with radiation or chemotherapy, whether or not symptoms are present. The lymphoma often goes into remission, but it may recur many years later as an indolent form or as one of the aggressive kinds. In either case, chemotherapy is used again to treat the cancer. (Occasionally, radiation therapy is also used again, but not to treat the same area of the body.)
In addition to chemotherapy and radiation for treating non-Hodgkin’s lymphoma, a biological therapy called rituximab (Rituxan) is now available. Rituxan, a drug approved by the Food and Drug Administration in 1997 for the treatment of certain indolent lymphomas, is a monoclonal antibody. Monoclonal antibodies, which are genetically engineered in a laboratory, are designed to attach to certain substances on the surface of cancer cells. (Rituxan attaches to a substance called CD20, which is found on some types of indolent non-Hodgkin’s lymphoma cells.) The patient’s body recognizes the monoclonal antibody as an invader, and the immune system kills the cells to which it is attached.
Presently, chemotherapy and radiation therapy are the first treatments given for non-Hodgkin’s lymphoma, and Rituxan is used if these fail or cancer comes back after a remission. However, in the future, Rituxan may become the first line of therapy, depending on the results of research currently under way.
Another biological therapy is interferon. Interferon is a protein naturally produced by white blood cells to help the immune system fight infections. Some research has suggested that interferon can help shrink the tumors of certain types of non-Hodgkin’s lymphoma. It is still not clear, however, which patients are appropriate candidates for interferon therapy and whether it should be given to these patients in addition to chemotherapy.
Although indolent lymphomas are less responsive to treatment than aggressive varieties, this does not mean that the prognosis for indolent cancers is necessarily poor. In fact, indolent lymphomas can progress so slowly that treatment, although it may not cure the disease, can often prolong life to the point where an older adult lives a normal lifespan and dies from another cause.
Is there a lymphoma vaccine under development?
Yes. But, unlike conventional vaccines, the lymphoma vaccine is not intended to prevent lymphoma in healthy people. Rather, it is given to patients in remission from an indolent lymphoma to strengthen the body’s natural defenses to prevent a relapse. The vaccine contains a tiny amount of protein taken from the patient’s own tumor. This allows the body to detect the tumor protein and produce defenses against it, priming the immune system to be ready to destroy any cells it encounters that contain the tumor protein. In a study of 20 patients who were vaccinated, 18 remained in complete remission four years after the therapy began. A larger trial is now under way; however, it could take eight years to produce results.
The lymphoma vaccine will be an exciting addition to the therapeutic arsenal for fighting lymphomas.
Liver Cancer
About Liver Cancer
The liver is the largest organ inside the body, located on the right side of the abdomen under the rib cage. It performs many important functions, such as storing and breaking down nutrients they can be used by the body, and filtering and storing blood. A person cannot survive without his or her liver.
In the United States, approximately 15,300 people (10,000 men and 5,300 women) are diagnosed with liver cancer each year. About 13,800 people (8,500 men and 5,300 women) die from the disease.
As the statistics indicate, liver cancer is more common among men than women. But, overall, the cancer is relatively rare in North America and Europe. By contrast, in certain African and East Asian countries, it is the most common of all types of cancer. For reasons as yet unknown, it is becoming even more common in these countries and less common in the U.S. and Europe.
What are the different types of liver cancer?
There are many kinds of tumors than can originate in the liver. Of the four main types that are cancerous (angiosarcomas, cholangiocarcinomas, hepatoblastomas, and hepatocellular carcinomas), hepatocellular carcinoma (also called hepatoma or HCC), is by far the most common, accounting for about 84 percent of all liver cancer cases. HCC starts growing in the hepatocytes, the main type of cell found in the liver.
What are the risk factors for liver cancer?
A risk factor is anything that increases a person’s chance of getting a disease. There are several known risk factors for liver cancer: Certain types of viral hepatitis, including chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV), are associated with increased liver cancer risk. Scientists estimate that about 10–20 percent of people infected with HBV will develop liver cancer. The precise relationship between HCV and liver cancer incidence is still under study. Long-term exposure to aflatoxins – a group of carcinogenic chemicals produced by a fungus found in tropical and subtropical regions that often contaminates peanuts, wheat, soy beans, corn and rice – can raise the risk of liver cancer. Long-term use of anabolic steroids (male hormones) can slightly increase the risk of liver cancer. Anabolic steroids are used for treating men with abnormally low testosterone levels and for treating men and women with certain types of severe anemia (low red blood cell counts). These hormones are also sometimes abused by athletes trying to build their strength. In some parts of the world, contamination of drinking water with arsenic is a liver cancer risk factor. Long-term exposure to the industrial chemicals vinyl chloride and thorium dioxide, which are now either strictly regulated or banned from use, has been tied to liver cancer. Some studies suggest that tobacco use may be a liver cancer risk factor. Birth control pills (oral contraceptives) have been shown to raise the risk of liver cancer, but the studies suggesting this link involved versions of oral contraceptives that are no longer used. These older formulations of “the Pill” contained different types of estrogens and progesterones at far higher doses than current formulations. It is not known whether or not today’s oral contraceptives are associated with liver cancer. A history of other liver diseases, particularly cirrhosis of the liver, has been shown to raise the risk of liver cancer. Cirrhosis is a progressive disorder that causes formation of scar tissue in the liver, interfering with blood flow to the organ and with the ability of the liver to work properly. About 5–10 percent of people with cirrhosis of the liver develop liver cancer. Research also suggests that alcohol abuse and malnutrition can lead to both cirrhosis and liver cancer. Can anything be done to prevent liver cancer?
Preventing infection with hepatitis B and C will reduce the risk of liver cancer. Strategies for lowering the likelihood of contracting hepatitis include following safe sex practices, not sharing needles, and getting vaccinated against hepatitis B. (All children should be vaccinated to prevent infection with hepatitis B.)
To reduce the risk of cirrhosis of the liver, a known risk factor for liver cancer, avoid excessive alcohol consumption.
What are the signs and symptoms of liver cancer?
Unfortunately, the signs and symptoms of liver cancer do not become apparent until the disease has progressed to a late stage.What’s more, many of the symptoms are nonspecific, meaning they can be vague and caused by many conditions. If you experience any of the following symptoms, however, see a doctor as soon as possible: unexplained weight loss; persistent lack of appetite; persistent abdominal pain; persistent feeling of being very full after only a small meal; swelling of the abdominal area with or without breathing difficulties; sudden jaundice (yellow-green coloration of the skin and eyes); a sudden change in your condition if you have chronic hepatitis or cirrhosis; liver enlargement or a mass that can be felt in the liver area. What tests are used to diagnose liver cancer?
If liver cancer is suspected, the doctor will use several methods to diagnose the disease. First, the doctor will conduct a complete medical interview to look for risk factors and symptoms. Then he or she will perform a physical exam.
The doctor will also order certain diagnostic tests, most of them imaging tests to produce pictures of the liver and the surrounding organs. These tests may include: ultrasonography (ultrasound), which uses sound waves to generate images of the targeted area; computed tomography (CT scan), which is a specialized x-ray procedure in which x-rays are put together by a computer to create detailed cross-sectional images of the body; and magnetic resonance imaging (MRI), in which images are produced using a magnetic field. In addition, angiography – an x-ray procedure for examining blood vessels – may be done to allow the doctor to examine the arteries that supply blood to a tumor.
A laparoscopy is a method used to examine the liver directly through a thin, lighted tube inserted through a small incision in the front of the abdomen. The laparoscopy affords the doctor a clear view of the liver and surrounding organs, which can help the doctor plan for surgery or other treatments. It is also an opportunity for the doctor to remove a small sample of tissue, called a biopsy, for examination under a microscope. A biopsy is the only way to know for sure whether cancer is present.
In addition, the doctor may order an alpha-fetoprotein (AFP) blood test, which is a tumor marker study. Tumor markers are substances that are found at elevated levels in the blood of people with certain cancers. AFP levels are routinely checked in patients with suspected liver cancer.
Liver function tests – blood tests that take a detailed look at certain aspects of liver function – are also often ordered if cancer is suspected, particularly in people with known chronic liver disease. Abnormal results (such as alkaline phosphatase) can be a sign of cancer.
Once liver cancer is diagnosed, more tests will be performed to determine the extent of the disease (for example, chest x-rays and bone scans). This is called staging. The stage of a cancer is the most significant factor when devising a treatment plan.
What are the stages of liver cancer?
For liver cancer, the system used to stage the disease is the TNM system (also known as the American Joint Committee on Cancer, or AJCC, system). This system is based on three main variables. The “T,” which stands for tumor, is followed by a number ranging from 1 to 4, and this indicates the extent to which the tumor has spread within the liver and to nearby organs. The “N,” which is followed by a 0 or 1, indicates whether the cancer has spread to regional (nearby) lymph nodes – small collections of immune system cells that help fight infections – and how large those lymph nodes are. And the “M,” followed by a 0 or 1, tells whether the cancer has spread to distant organs in the body or to lymph nodes not located near the liver.
The TNM system is used to categorize the cancer in stages I through IV. The higher the stage number, the more the cancer has spread. Some doctors also divide the stages into letters (for example, IA or IB) to further clarify the extent of the cancer.
How is liver cancer treated?
Treatment of liver cancer depends on the type of tumor and the stage ofthe disease, the condition of the liver, and the patient’s age and overall health. The three main treatment methods include surgery, chemotherapy, and radiation therapy. Frequently, a combination of treatments is recommended.
Surgery to remove a tumor, called surgical resection, is the only way to cure liver cancer. Unfortunately, in the majority of liver cancers, complete removal of the cancer is not possible, either because the cancer has already spread beyond the liver or because the tumor is too large, or several tumors are present in different parts of the liver. Moreover, about 30 percent of hepatocellular carcinoma (HCC) patients in the U.S. have cirrhosis. This makes removal of even a small amount of liver tissue at the perimeter of the cancer prohibitive, as it would not leave enough liver tissue to perform the essential functions of the organ.
There are two other surgical methods for destroying liver tumors without removing them. The first is called cryosurgery, in which the tumor is destroyed by freezing it with a metal probe. The second is called ethanol ablation, which involves injecting alcohol directly into the tumor to destroy the cancer cells.
Chemotherapy, the use of cancer-killing drugs, is also used to treat liver cancer. Chemotherapy can be administered systemically by injection into a vein (IV) or by mouth. In systemic chemotherapy, the anticancer drugs enter the bloodstream and travel throughout the whole body, attacking cancer cells found beyond the liver. A combination of anticancer drugs is usually used, typically given in cycles (a period of treatment followed by a period of recovery, then another treatment period, etc.).
Systemic chemotherapy often does not work well for liver cancer. Another method, called hepatic artery infusion (a type of regional chemotherapy), may therefore be used. In this procedure, the anticancer drugs are injected directly into the artery that supplies the liver with blood. This allows high doses to reach the cancer. The procedure can be administered on an outpatient basis using a small pump placed just beneath the skin.
Radiation therapy, in which high-energy rays are used to kill cancer cells, is not often used for liver cancer, as studies do not demonstrate a strong effect on survival rates. However, researchers are investigating new techniques for administering radiation, as well as new combinations of radiation therapy and chemotherapy.
The liver is the largest organ inside the body, located on the right side of the abdomen under the rib cage. It performs many important functions, such as storing and breaking down nutrients they can be used by the body, and filtering and storing blood. A person cannot survive without his or her liver.
In the United States, approximately 15,300 people (10,000 men and 5,300 women) are diagnosed with liver cancer each year. About 13,800 people (8,500 men and 5,300 women) die from the disease.
As the statistics indicate, liver cancer is more common among men than women. But, overall, the cancer is relatively rare in North America and Europe. By contrast, in certain African and East Asian countries, it is the most common of all types of cancer. For reasons as yet unknown, it is becoming even more common in these countries and less common in the U.S. and Europe.
What are the different types of liver cancer?
There are many kinds of tumors than can originate in the liver. Of the four main types that are cancerous (angiosarcomas, cholangiocarcinomas, hepatoblastomas, and hepatocellular carcinomas), hepatocellular carcinoma (also called hepatoma or HCC), is by far the most common, accounting for about 84 percent of all liver cancer cases. HCC starts growing in the hepatocytes, the main type of cell found in the liver.
What are the risk factors for liver cancer?
A risk factor is anything that increases a person’s chance of getting a disease. There are several known risk factors for liver cancer: Certain types of viral hepatitis, including chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV), are associated with increased liver cancer risk. Scientists estimate that about 10–20 percent of people infected with HBV will develop liver cancer. The precise relationship between HCV and liver cancer incidence is still under study. Long-term exposure to aflatoxins – a group of carcinogenic chemicals produced by a fungus found in tropical and subtropical regions that often contaminates peanuts, wheat, soy beans, corn and rice – can raise the risk of liver cancer. Long-term use of anabolic steroids (male hormones) can slightly increase the risk of liver cancer. Anabolic steroids are used for treating men with abnormally low testosterone levels and for treating men and women with certain types of severe anemia (low red blood cell counts). These hormones are also sometimes abused by athletes trying to build their strength. In some parts of the world, contamination of drinking water with arsenic is a liver cancer risk factor. Long-term exposure to the industrial chemicals vinyl chloride and thorium dioxide, which are now either strictly regulated or banned from use, has been tied to liver cancer. Some studies suggest that tobacco use may be a liver cancer risk factor. Birth control pills (oral contraceptives) have been shown to raise the risk of liver cancer, but the studies suggesting this link involved versions of oral contraceptives that are no longer used. These older formulations of “the Pill” contained different types of estrogens and progesterones at far higher doses than current formulations. It is not known whether or not today’s oral contraceptives are associated with liver cancer. A history of other liver diseases, particularly cirrhosis of the liver, has been shown to raise the risk of liver cancer. Cirrhosis is a progressive disorder that causes formation of scar tissue in the liver, interfering with blood flow to the organ and with the ability of the liver to work properly. About 5–10 percent of people with cirrhosis of the liver develop liver cancer. Research also suggests that alcohol abuse and malnutrition can lead to both cirrhosis and liver cancer. Can anything be done to prevent liver cancer?
Preventing infection with hepatitis B and C will reduce the risk of liver cancer. Strategies for lowering the likelihood of contracting hepatitis include following safe sex practices, not sharing needles, and getting vaccinated against hepatitis B. (All children should be vaccinated to prevent infection with hepatitis B.)
To reduce the risk of cirrhosis of the liver, a known risk factor for liver cancer, avoid excessive alcohol consumption.
What are the signs and symptoms of liver cancer?
Unfortunately, the signs and symptoms of liver cancer do not become apparent until the disease has progressed to a late stage.What’s more, many of the symptoms are nonspecific, meaning they can be vague and caused by many conditions. If you experience any of the following symptoms, however, see a doctor as soon as possible: unexplained weight loss; persistent lack of appetite; persistent abdominal pain; persistent feeling of being very full after only a small meal; swelling of the abdominal area with or without breathing difficulties; sudden jaundice (yellow-green coloration of the skin and eyes); a sudden change in your condition if you have chronic hepatitis or cirrhosis; liver enlargement or a mass that can be felt in the liver area. What tests are used to diagnose liver cancer?
If liver cancer is suspected, the doctor will use several methods to diagnose the disease. First, the doctor will conduct a complete medical interview to look for risk factors and symptoms. Then he or she will perform a physical exam.
The doctor will also order certain diagnostic tests, most of them imaging tests to produce pictures of the liver and the surrounding organs. These tests may include: ultrasonography (ultrasound), which uses sound waves to generate images of the targeted area; computed tomography (CT scan), which is a specialized x-ray procedure in which x-rays are put together by a computer to create detailed cross-sectional images of the body; and magnetic resonance imaging (MRI), in which images are produced using a magnetic field. In addition, angiography – an x-ray procedure for examining blood vessels – may be done to allow the doctor to examine the arteries that supply blood to a tumor.
A laparoscopy is a method used to examine the liver directly through a thin, lighted tube inserted through a small incision in the front of the abdomen. The laparoscopy affords the doctor a clear view of the liver and surrounding organs, which can help the doctor plan for surgery or other treatments. It is also an opportunity for the doctor to remove a small sample of tissue, called a biopsy, for examination under a microscope. A biopsy is the only way to know for sure whether cancer is present.
In addition, the doctor may order an alpha-fetoprotein (AFP) blood test, which is a tumor marker study. Tumor markers are substances that are found at elevated levels in the blood of people with certain cancers. AFP levels are routinely checked in patients with suspected liver cancer.
Liver function tests – blood tests that take a detailed look at certain aspects of liver function – are also often ordered if cancer is suspected, particularly in people with known chronic liver disease. Abnormal results (such as alkaline phosphatase) can be a sign of cancer.
Once liver cancer is diagnosed, more tests will be performed to determine the extent of the disease (for example, chest x-rays and bone scans). This is called staging. The stage of a cancer is the most significant factor when devising a treatment plan.
What are the stages of liver cancer?
For liver cancer, the system used to stage the disease is the TNM system (also known as the American Joint Committee on Cancer, or AJCC, system). This system is based on three main variables. The “T,” which stands for tumor, is followed by a number ranging from 1 to 4, and this indicates the extent to which the tumor has spread within the liver and to nearby organs. The “N,” which is followed by a 0 or 1, indicates whether the cancer has spread to regional (nearby) lymph nodes – small collections of immune system cells that help fight infections – and how large those lymph nodes are. And the “M,” followed by a 0 or 1, tells whether the cancer has spread to distant organs in the body or to lymph nodes not located near the liver.
The TNM system is used to categorize the cancer in stages I through IV. The higher the stage number, the more the cancer has spread. Some doctors also divide the stages into letters (for example, IA or IB) to further clarify the extent of the cancer.
How is liver cancer treated?
Treatment of liver cancer depends on the type of tumor and the stage ofthe disease, the condition of the liver, and the patient’s age and overall health. The three main treatment methods include surgery, chemotherapy, and radiation therapy. Frequently, a combination of treatments is recommended.
Surgery to remove a tumor, called surgical resection, is the only way to cure liver cancer. Unfortunately, in the majority of liver cancers, complete removal of the cancer is not possible, either because the cancer has already spread beyond the liver or because the tumor is too large, or several tumors are present in different parts of the liver. Moreover, about 30 percent of hepatocellular carcinoma (HCC) patients in the U.S. have cirrhosis. This makes removal of even a small amount of liver tissue at the perimeter of the cancer prohibitive, as it would not leave enough liver tissue to perform the essential functions of the organ.
There are two other surgical methods for destroying liver tumors without removing them. The first is called cryosurgery, in which the tumor is destroyed by freezing it with a metal probe. The second is called ethanol ablation, which involves injecting alcohol directly into the tumor to destroy the cancer cells.
Chemotherapy, the use of cancer-killing drugs, is also used to treat liver cancer. Chemotherapy can be administered systemically by injection into a vein (IV) or by mouth. In systemic chemotherapy, the anticancer drugs enter the bloodstream and travel throughout the whole body, attacking cancer cells found beyond the liver. A combination of anticancer drugs is usually used, typically given in cycles (a period of treatment followed by a period of recovery, then another treatment period, etc.).
Systemic chemotherapy often does not work well for liver cancer. Another method, called hepatic artery infusion (a type of regional chemotherapy), may therefore be used. In this procedure, the anticancer drugs are injected directly into the artery that supplies the liver with blood. This allows high doses to reach the cancer. The procedure can be administered on an outpatient basis using a small pump placed just beneath the skin.
Radiation therapy, in which high-energy rays are used to kill cancer cells, is not often used for liver cancer, as studies do not demonstrate a strong effect on survival rates. However, researchers are investigating new techniques for administering radiation, as well as new combinations of radiation therapy and chemotherapy.
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