Kidney Cancer

What is the Kidney?
The kidneys are two bean-shaped organs that have many important functions essential for life. Among the most important are filtrating the blood, removing waste products from the blood and ensuring that the electrolytes within the blood are correct. In addition, the kidneys produce erythropoetin, a hormone responsible for the production of (the oxygen carrying) red blood cells. The kidneys can be divided into two main functional parts. The outer region of the kidneys is called the cortex, and, as it is responsible for the filtration of blood, it consists of series of collecting tubules. The inner region of the kidneys contain medullary pyramids that collect the filtrate (urine) from these collecting tubules and send it to the urinary bladder via the ureters. This inner region is called the renal pelvis. Different types of cancers develop from the two different regions of the kidneys.
The kidneys are located in the posterior aspect of the abdomen, basically directly in front of where the lowest ribs can be felt on a person's back. A physician can palpate them in the abdomen at times, though often only if the kidney is enlarged or has a mass on it.
What is kidney cancer?
The definition of a tumor is a mass of quickly and abnormally growing cells. Tumors can be either benign or malignant. Benign tumors have uncontrolled cell growth, but without any invasion into normal tissues and without any spread. A malignant tumor is called cancer when these tumor cells gain the propensity to invade tissues and spread locally as well as to distant parts of the body. In this sense, kidney cancer occurs when cells in either the cortex of the kidney or cells in the renal pelvis grow uncontrollably and form tumors that can invade normal tissues and spread to other parts of the body.
Cancers are described by the types of cells from which they arise. Again, when discussing kidney cancer, the cortex and the renal pelvis must be mentioned separately. In the kidney cortex, the vast majority of cancers arise from the cells that line the collecting tubules, more specifically, the proximal tubules. Cancers that develop from lining such as this are called carcinomas. In this case, they are obviously called renal cell carcinomas. Over 75% of renal cell carcinomas are called clear cell carcinomas, named after the characteristics they display when looking at them under the microscope. Other classifications, in decreasing order of prevalence, include chromophilic, chromophobic, oncocytic, and collecting duct cancers. However, it does not appear that these various types of renal cell carcinoma differ in presentation or prognosis.
Cancers of the renal pelvis, or medulla, are uncommon. Over 90% of cancers that develop in the renal pelvis are called transitional cell carcinomas. They are so named because they develop from cells that line the renal pelvis and upper ureters.
Am I at risk for kidney cancer?
Kidney cancer occurs in approximately 31,000 Americans per year and cancers of the renal pelvis will occur in approximately 3,000 Americans per year. Most patients are diagnosed between the ages of 50 and 70. It is more common in men than women with an equal preponderance in whites and blacks. A number of risk factors are associated with an increased probability of renal cell cancer, though the most prominent risk is cigarette smoking. Persons who smoke have twice the risk of developing kidney cancer, and smoking is directly responsible for up to one out of every three cancers. The risk for kidney cancer also increases fourfold in persons with a first-degree relative who had kidney cancer. Other, less-proven risk factors include obesity (especially in women), analgesic abuse, high blood pressure, and several uncommon hereditary diseases, including von Hippel-Lindau disease and polycystic disease.
How can I prevent kidney cancer?
As cigarette smoking doubles the risk of kidney cancer, the best way to decrease your risk of developing kidney cancer is to discontinue smoking. Other than smoking, the only substantial risk factors for the development of kidney cancer are related to family pedigree. Obviously, no one can change the family they are born into, so the risk factor of having someone in the family with a history of kidney cancer, or rare genetic diseases such as von Hippel Lindau and polycystic disease cannot be prevented.
What screening tests are available?
There are screening tests for kidney cancer that are akin to mammography or colonoscopy. However, the use of CT scans and ultrasounds have enhanced the early detection of kidney cancer once signs or symptoms have developed (see below). Kidney cancers that develop in the area of the collecting system (the inner portion of the kidney) are prone to earlier detection because of intravenous pyelograms (IVPs) and urine cytology. IVPs are done by injecting dye into a patient's arm and then taking x-rays of the abdomen to see that dye subsequently excreted by the kidneys as urine. Cytology is simply looking at urine under a microscope and looking for cancerous cells within the urine.
What are signs of kidney cancer?
Kidney cancer presents as signs and symptoms of either the local tumor in the kidney or as signs and symptoms resulting from spread of disease to other locations in the body (metastatic disease). Symptoms resulting from local tumor extension include hematuria (blood in the urine), abdominal pain, and a flank mass. Hematuria is the most common symptom and present as either gross hematuria, where the blood is visible in the urine, or as microscopic hematuria, where the blood is only detected by laboratory testing. Therefore, any presence of blood in the urine that is detected in a urine sample should be investigated. In medical textbooks, patients present with the "classic triad" of all three symptoms, though only about 10% actually have all three symptoms at diagnosis.
Symptoms caused by metastatic disease include fever, weight loss, and night sweats (drenching sweats that require changing of clothes or bedsheets). Other symptoms include hypertension, increased calcium in the blood, and liver problems. These more unique symptoms are thought to be caused by chemical signals released by the tumor cells into the bloodstream and the body's reaction to them.
With the advent of CT scans and ultrasounds, 25-40% of kidney cancers are now detected incidentally during the work up of a different problem. These tumors are more likely to be smaller (hence causing no symptoms), and hence more likely to result in a cure.
How is kidney cancer diagnosed and staged?
Diagnosis
Work up of a kidney cancer usually starts after the patient presents with symptoms, with the exception of those cancers that are found incidentally. The entire point of all of the tests done prior to treatment of kidney cancer is to determine the extent of disease that is present so that treatment can be adjusted accordingly. This includes documenting the extent of disease both locally, in the tissues and lymph nodes surrounding the kidney, as well as ensuring there is no spread distantly, outside the area of the kidney (called metastases). The most sensitive test to document local disease is the CT scan, which has been shown to predict the tumor extent preoperatively in 90% of patients. MRI scans have been used to ensure the tumor has not involved any of the large blood vessels that are in the vicinity of the kidney. Other tests, including basic laboratory blood tests and analysis of the urine. In addition, a chest x-ray and bone scan are usually done, to ensure against metastatic spread to the lungs and bones, respectively. In the case of cancers within the inner part of the kidney (the collecting system), the IVP is an additional test that is extremely important to not only document the local extent of tumor, but also to ensure against simultaneous tumors somewhere else in the urine collecting system
To obtain a diagnosis of any cancer, tissue or cells must be examined by a pathologist. Therefore, to obtain a diagnosis of kidney cancer, a biopsy is often obtained by inserting a needle into the presumed tumor mass during a CT scan. However, there are also times that the CT scan and/or MRI is so convincing that the mass is a tumor, that the initial biopsy is done during an open surgical procedure, which is done to ultimately remove the kidney, as treatment for the kidney cancer. This, obviously, must be determined on an individual basis.
Staging
After all of these tests are performed, the stage of the cancer is known. The staging of a cancer basically describes how much it is grown before the diagnosis has been made, documenting the extent of disease. This is often extremely important in terms of what treatment is offered to each individual patient. Before the staging systems are introduced, first some background on how cancers grow and spread, and therefore advance in stage.
Cancers cause problems because they spread and can disrupt the functioning of normal organs. One way kidney cancer can spread is by local extension to invade through the normal structures. This initially includes the kidney, hence giving the symptoms of hematuria, a mass and abdominal pain. If more growth occurs, it could grow to involve the main vein that leaves the kidney (the renal vein), the large vein that returns blood from the bottom half of the body to the heart (the inferior vena cava), or into other organs-most commonly the adrenal glands.
Kidney cancer can also spread by accessing the lymphatic system. The lymphatic circulation is a complete circulation system in the body (somewhat like the blood circulatory system) that drains into various lymph nodes. When cancer cells access this lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is called lymphatic spread. Kidney cancer can spread, at times, into the lymph nodes surrounding the kidney, called the perirenal lymph nodes.
Kidney cancers can also spread through the bloodstream. Cancer cells gain access to distant organs via the bloodstream and the tumors that arise from cells' travel to other organs are called metastases. Cancers of the kidney generally spread locally into the fat surrounding the kidney, the adrenal glands, or the veins prior to spreading via the lymphatic system or the bloodstream. However, tumors, especially larger tumors, can access the bloodstream and spread to the lungs and bones, most commonly. Kidney tumors have also been known to spread to the testis and ovaries through the testicular or ovarian veins that are in close proximity to the kidney.
The staging system used today in kidney cancer is designed to describe the extent of disease within the area of the kidney, in the surrounding lymph nodes, and distantly. The staging system most commonly used today to describe kidney tumors is the "TNM system", as described by the American Joint Committee on Cancer. This replaced the "Robson Modification of the Flocks and Kadesky Staging System" because of its superiority in describing the local extent and lymph node involvement. The TNM systems are used to describe many types of cancers. They have three components: T-describing the extent of the "primary" tumor (the tumor in the esophagus itself); N-describing the spread to the lymph nodes; M-describing the spread to other organs (i.e.-metastases).
The "T" stage is as follows:
For kidney (cortex) tumors:
T1-tumor size of 7 cm or less and confined to the kidney
T2-tumor size more than 7 cm, but still confined to the kidney
T3a-tumor invading into the adrenal gland or just outside of the kidney
T3b-tumor invading into the renal vein or inferior vena cava, but contained below the diaphragm
T3c- tumor invading into the renal vein or inferior vena cava, but extending above the diaphragm
T4-tumor invades outside of these areas
For collecting system tumors:
T1-tumor contained within the collecting system
T2-tumor invades into the muscular layer of the wall of the collecting system
T3-tumor invades into the fat surrounding the collecting system
T4-tumor invades into other organs
The "N" stage is as follows for any subsite:
N0-no spread to lymph nodes
N1-tumor spread to a single lymph node
N2-tumor spread to multiple lymph nodes or for collecting system tumors, lymph node spread that is between 2 and 5 cm
N3-for collecting system tumors only, those lymph nodes that are >5 cm
The "M" stage is as follows:
M0-no tumor spread to other organs
M1-tumor spread to other organs
The overall stage is based on a combination of these T, N, and M parameters: For kidney cortex tumors
Stage I: T1N0M0
Stage II: T2N0M0
Stage III:
T1-2N1M0
T3N0-1M0
Stage IV: and T4, any N2 or M1 For collecting system tumors
Stage I: T1N0M0
Stage II: T2N0M0
Stage III: T3N0M0
Stage IV: any T4, any N1-3, any M1
Though complicated, these staging systems help physicians determine the extent of the cancer, and therefore make treatment decisions regarding a patient's cancer.
What are the treatments for kidney cancer?
Surgical resection (removal) is the only possible curative treatment for kidney cancer. The procedure that is done in the case of kidney cancer is called a radical nephrectomy. This procedure includes the removal of the entire kidney that is involved with tumor as well as the adrenal gland associated with the kidney and subsequently, the fat surrounding the kidney and adrenal gland. The surgical procedure also usually includes removing at least some of the lymph nodes surrounding the kidney, which has shown to increase survival in patients with kidney cancer. So-called partial nephrectomies (where only a part of the kidney is removed) has been attempted in some patients with small tumors. This should only be attempted in patients with tumors <4cm. If the tumor can be completely removed, the risk of the tumor coming back in the region of the kidney is about 5%. Therefore, this treatment is very effective.
Even if the kidney cancer has spread to a single different part of the body, a nephrectomy may be recommended, as it has been shown to improve survival. If there are many sites of disease, however, nephrectomy has not been shown to be useful.
Radiation therapy makes the use of high energy x-rays to kill cancer cells. It does this by damaging the DNA in tumor cells. Normal cells in our body can repair radiation damage much quicker than tumor cells, so while tumor cells are killed by radiation, many normal cells are not. This is the basis for the use of radiation therapy in cancer treatment. Radiation is delivered using large machines that produce the high energy x-rays. Radiation therapy, however, is not routinely used in the initial treatment of kidney cancer. As the local failure in patients with complete removal of the tumor is 5%, adding local radiation, which is done to improve local control of a tumor, would do little to improve results. In patients without a complete removal of tumor, there could be a role for postoperative radiation therapy, though it should only be done as part of an investigational trial.
Chemotherapy is defined as drugs that are used to kill tumor cells. Up to this point, there is no chemotherapy regimen that has been consistently shown to be efficacious in the treatment of curative or metastatic kidney cancer. New modalities are constantly being investigated, including interferon, anti-angiogenesis agents (which inhibit the tumor from growing more blood vessels), and molecular agents that target specific genes that may be essential for the tumor cells' survivals.

Gastric Cancer: The Basics

What is the stomach?
Gastric cancer is cancer of the stomach. The stomach is the organ that holds and stores food. Its shape is a large pouch located just underneath (deep to) the lower portion of the rib cage on the left side. It is connected to the mouth and throat by the esophagus. Quite a bit of digestion takes place in the stomach, at which point this partially digested food is emptied into the small intestine so that absorption of the nutrients from food can take place. Although the stomach obviously cannot be directly visualized, it can be seen via an endoscopy procedure (see below).
What is gastric cancer?
The definition of a tumor is a mass of quickly and abnormally growing cells. Tumors can be either benign or malignant. Benign tumors have uncontrolled cell growth, but without any invasion into normal tissues and without any spread. A malignant tumor is called cancer when these tumor cells gain the propensity to invade tissues and spread locally as well as to distant parts of the body. In this sense, gastric cancer occurs when cells in the lining of the stomach grow uncontrollably and form tumors that can invade normal tissues and spread to other parts of the body.
Cancers are described by the types of cells from which they arise. Over 90% of gastric cancers arise from the lining of the stomach. Since this lining has glands, the cancer that comes from it is called adenocarcinoma. Although there are other cancers that can arise in the stomach (lymphomas-from lymph tissue, leiomyosarcoma-from muscle tissue, squamous cell carcinoma-from lining without glands), the vast majority are adenocarcinomas. Hence, these are the most commonly studied.
Am I at risk for gastric cancer?
In the United States, gastric cancer now ranks as the 14th most common cancer. Its incidence has drastically decreased since 1930. Although it is presumed that this is due to some sort of dietary or environmental factor(s), the exact reason behind this decrease is not known. It is approximately twice as common in men and more common in Blacks than Caucasians. It is rare to see gastric cancer before the age of 40, and its incidence increases with age thereafter.
Although gastric cancer has greatly decreased in the United States, on a worldwide scale its incidence is still high and is still a leading cause of cancer death. Its highest incidence is in East Asia (e.g.-Japan, China), presumably because of a diet consisting of heavily smoked, salted, and pickled foods. The incidence greatly declines in second and third generation Japanese and Chinese immigrants to the United States; pointing to the fact that there is nothing inherently genetic in Eastern Asian persons' preponderance to gastric cancer, but rather the high incidence is due to something environmental.
As stated, diets heavily salted, smoked, or pickled are associated with an increased risk of disease while diets rich in fruits, vegetables, and dietary fiber are associated with a decreased risk of cancer. The incidence of gastric cancers also increases with decreasing socioeconomic status, likely due to a number of social, occupational, and cultural factors. Tobacco use has also been associated with an increase in gastric cancers.
Studies have also linked infection with Helicobacter pylori with gastric cancer. H. pylori is associated with gastric ulcers and chronic atrophic gastritis, which may explain the high incidence of gastric cancer in patients infected with H. pylori. However, the exact role of H. pylori in the development of gastric cancer remains unclear.
It should be noted that, although these risk factors are listed above, the majority of gastric cancers develop without any one obvious predisposing cause. In other words, there is no extremely strong cause effect relationship with any risk factor, in contrast, for example, to that between smoking and lung cancer.
How can I prevent gastric cancer?
Because there is no one risk factor directly associated with gastric cancer, there is no strict lifestyle change that can greatly decrease a person's risk of developing gastric cancer. However, eating a "Western" type diet, without heavily smoked or salted foods and rich in fruits and vegetables will likely decrease a person's risk. Also, smoking cessation will likely decrease gastric cancer risk (though smoking should be stopped for numerous other health reasons). Some have advocated the consumption of foods with high level of antioxidants and vitamin C to prevent gastric cancers, though this has not been definitively proven. Since H. pylori infections have been linked to the development of gastric cancers, the quick treatment of H. pylori infections would likely decrease the numbers of gastric cancers. Obviously, identifying people with asymptomatic H. pylori infections would be difficult, the fact remains that people with gastric ulcers or atrophic gastritis caused by H pylori should be treated with antibiotics.
What screening tests are available?
There are no established programs for primary prevention of gastric cancer in the United States. There are no plans to initiate a screening program in the United States simply because the incidence of gastric cancer is fairly low and the yield from gastric cancer screening would be far too low to approach cost-effectiveness. A few populations may be exceptions (e.g.-patients with known atrophic gastritis), but overall screening for gastric cancer in the United States would likely cause more problems than they would solve.
In some Japanese centers, where gastric cancer is much more prevalent, screening has been more successful. A variety of tests have been used in these screening programs, with the ability to accurately identify gastric cancers in over 90% of patients who have gastric cancer. These tests include double-contrast barium radiographs (so-call "upper GIs" or "barium swallows") and upper endoscopies. An upper endoscopy (or an "EGD") is a test done using a camera at the end of a long tube that is placed down the patient's throat to the stomach itself. The physician performing the EGD is able to directly visualize the stomach. Many abnormalities can be detected with an EGD-most importantly, ulcers and cancers. Patients are sedated during the procedure, so discomfort is kept to a minimum.
More recently, studies have verified the use of a newer blood test that could be used for screening for gastric cancer. This analyzes the presence of enzymes in the blood called the serum pepsinogen I/II ratio, which is low in patients at risk for atrophic gastritis and gastric cancer. However, this is still in the earlier stage of testing and needs to be verified.
What are the signs of gastric cancer?
The symptoms of gastric cancer are often nonspecific. The vast majority of gastric cancer patients present with vague complaints such as upper abdominal discomfort or indigestion, loss of appetite, occasional vomiting, belching, or decreased ability to eat a large meal. Unfortunately, these symptoms are often the exact symptoms that patients experience when they have peptic ulcer disease or gastritis. Therefore, patients can be treated for benign diseases, such as ulcers, without the diagnosis of gastric cancers being made. This is not incorrect management, as gastritis and peptic ulcer disease are much more common than gastric cancer. However, if symptoms persist or do not respond to treatment, further investigations should follow.
Other symptoms, such as vomiting blood or problems with swallowing are less common, but should be investigated without delay. Additional symptoms that generally apply to cancer patients are unexplained weight loss as well as fatigue and weakness, with or without anemia. Again, these symptoms are, unfortunately, nondescript and do not necessarily apply to cancer in general or gastric cancer specifically, at all.
How is gastric cancer diagnosed and staged?
Staging
The staging of a cancer basically describes how much it is grown before the diagnosis has been made, documenting the extent of disease. Unfortunately, gastric cancer often presents as a more advanced disease because of lack of early diagnosis, due mainly to the lack of specific symptoms that are associated with it. Before the staging systems are introduced, some background on how cancers grow and spread, and therefore advance in stage.
Cancers cause problems because they spread and can disrupt the functioning of normal organs. One way gastric cancer can spread is by local extension to invade through the stomach wall and into adjacent structures. These surrounding structures include the soft tissues and fat surrounding the stomach as well as other organs such as the spleen, pancreas, large intestine, small intestine, liver, and large blood vessels.
Gastric cancer can also spread by accessing the lymphatic system. The lymphatic circulation is a complete circulation system in the body (somewhat like the blood circulatory system) that drains into various lymph nodes. When cancer cells access this lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is called lymphatic spread. Gastric cancers have a propensity to undergo lymphatic spread because there are many small lymphatic vessels contained within the stomach wall. The first lymph nodes that cancer cells spread to are the "perigastric" nodes along the sides of the stomach itself. They can then spread to lymph nodes adjacent to the liver, spleen, pancreas, and aorta.
Gastric cancers can also spread through the bloodstream. Cancer cells gain access to distant organs via the bloodstream and the tumors that arise from cells' travel to other organs are called metastases. Because of the stomach's blood supply, the most common organ it spreads to is the liver, though tumors can also spread to the lung or other organs less commonly.
A fourth way gastric cancer can spread is throughout the entire abdomen, the so-called peritoneal cavity. Although rare, once cancer cells grow outside of the stomach itself, there is nothing stopping cells from spreading to any surface in the entire abdominal cavity.
There are two accepted staging systems in gastric cancer. They both detail the extent of disease by describing the growth of tumor in the stomach itself as well as the presence and extent of spread to the lymph nodes. First, is described the TNM Staging, then the older Modified Astler-Coller staging system is related. The TNM systems are used to describe many types of cancers. They have three components: T-describing the extent of the "primary" tumor (the tumor in the stomach itself); N-describing the spread to the lymph nodes; M-describing the spread to other organs (i.e.-metastases).
The "T" stage is as follows:
Tis-"in-situ cancer"-very superficial tumor, without invasion of the stomach wall
T1-tumor invades into only the superficial portions of the stomach wall
T2-tumor invades into the deeper layers of the stomach wall
T3-tumor extends through the stomach wall into the fat outside of the stomach
T4-tumor extends outside the stomach wall and invades into other organs
The "N" stage is as follows:
N0-no spread to lymph nodes
N1-tumor spread to 1-6 lymph nodes
N2-tumor spread to 7-15 lymph nodes
N3-tumor spread to more than 15 lymph nodes
The "M" stage is as follows:
M0-no tumor spread to other organs
M1-tumor spread to other organs
The overall stage is based on a combination of these T, N, and M parameters:
Stage IA-T1N0M0
Stage IB-T1N1M0 or T2N0M0
Stage II-T1N2M0 or T2N1M0 or T3N0M0
Stage IIIA-T2N2M0 or T3N1M0 or T4N0M0
Stage IIIB-T3N2M0 or T4N1M0
Stage IV-T4N2M0 or T1-3N3M0 or T4N2-3M0 or any M1
The Modified Astler-Coller (MAC) system is simpler (thankfully), but can be corresponded to the TNM system:
MAC system
TNM stage
Characteristics
A
TisN0M0
lymph nodes not involved; tumor very superficial in stomach
B1
T1-2N0M0
lymph nodes not involved; tumor deeper, but still within stomach wall (not entire way through)
B2
T3N0M0
lymph nodes not involved; tumor through the stomach wall
B3
T4N0M0
lymph odes not involved; tumor invading into other organs
C1
Tis-2N1-3M0
lymph nodes involved, but tumor not through the stomach wall
C2
T3N1-3M0
lymph nodes involved and tumor through the stomach wall
C3
T4N1-3M0
lymph nodes involved and tumorinvading into other organs
Though complicated, these staging systems help physicians determine the extent of the cancer, and therefore make treatment decisions regarding a patient's cancer. The stage of cancer, or extent of disease, is based on information gathered through various tests done as the diagnosis and work-up of the cancer is being performed.
Diagnosis
Upper endoscopy, as described above, is routinely used for the initial diagnosis and staging of patients with gastric cancer. Using endoscopy, the diagnosis can be obtained in over 95% of cases. Many times, ultrasound during endoscopy is used to attempt to identify how deep into the wall of the stomach the cancer has penetrated. In addition, ultrasound can identify spread to lymph nodes in many cases. Depth of wall invasion and presence of lymph node spread are two very important components of treatment, as the surgeon uses this information to determine if he or she can operate.
Other procedures are needed to determine the stage of the patient. CT scans ("CAT scans") of the abdomen and chest are done, not only to rule out spread to distant organs, like the liver and lungs, but also to determine the spread to lymph nodes close to the stomach that could not be identified by ultrasound. Other tests to rule out abdominal spread of disease outside of the stomach itself are PET scans, which use radioactive solutions to identify tumors, and laparoscopy. Laparoscopy is a more minor surgical procedure that involves puncturing the abdominal cavity with a fiber optic camera and directly viewing the organs and tissues in the stomach's area and the entire abdominal cavity. Although PET scans and laparoscopy are fairly new introductions to the staging of gastric cancer, CT scans, endoscopy, and ultrasound are more generally accepted as required in order to properly identify the extent of disease, and all will likely be done in a patient diagnosed with gastric cancer.
Other, more routine tests done before treatment include blood screening tests, to insure that overall blood counts are within normal limits, and that a patient's liver, kidneys, and overall health are normal.
What are the treatments for gastric cancer?
Currently, all curative treatments for gastric cancer involve surgery (surgical resection of all of the cancer). The smallest amount of surgery that is possible while still taking out all of the cancer is what is normally performed. If the tumor involving the stomach is fairly small, many times a partial gastrectomy can be performed. A partial gastrectomy is the removal of only a portion of the stomach, in contrast to a total gastrectomy, which is done when the tumor is larger. Usually, a partial gastrectomy is adequate, as long as the surgeon can remove the entire tumor with some normal stomach around it-this is called the surgical margin. The surgical margin in gastric cancer needs to be 5 cm, i.e., there needs to be 5 cm of normal stomach tissue around the tumor in the portion of the stomach removed. Often, this requires removal of the first portion of the small intestine and the fat tissue surrounding the stomach. Additionally, if the tumor has grown outside of the stomach or into organs, a portion of these organs must also be resected (taken out). This often requires removal of the spleen, a portion of the pancreas, or a portion of the small intestine, as above. Also, the surgeon performs a complete dissection of the lymph nodes, removing as many as possible. Although the extent of lymph nodes required to be removed is somewhat controversial, an extensive removal of lymph nodes is reasonable if it is done by an experienced surgeon who can perform it without additional side effects. Obviously, when the stomach or a portion of the stomach is removed, the two ends must be rejoined. This is done by various procedures, all attempting to eliminate as much side effect to the surgery as possible, which can include not being able to eat more than small meals and so-called "dumping syndrome". Dumping syndrome results from the stomach being removed and the result of the small intestine filling too rapidly with undigested food. Symptoms include nausea, vomiting, bloating, diarrhea, and even shortness of breath. These symptoms can usually be managed with dietary modifications.
Although surgery is always required for curative treatment, it is often not enough to achieve cure in many cases. The majority of cases of early gastric cancer are cured by surgery alone. However, in most patients with more advanced cases of gastric cancer, the cancer will come back if only surgery is done. Up to two-thirds of these patients recur with cancer coming back in their lymph nodes with some additional patients recurring with cancer in other organs. To combat this, radiation therapy and chemotherapy are recommended in many patients. It is felt that any patient with stage IB or higher gastric cancer (involvement of deeper portions of the stomach wall or any lymph nodes involved with cancer) will benefit from additional therapy with radiation and chemotherapy.
Radiation therapy makes the use of high energy x-rays to kill cancer cells. It does this by damaging the DNA in tumor cells. Normal cells in our body can repair radiation damage much quicker than tumor cells, so while tumor cells are killed by radiation, many normal cells are not. This is the basis for the use of radiation therapy in cancer treatment. Radiation is delivered using large machines that produce the high energy x-rays. After radiation oncologists set up the radiation fields ("radiation fields" are the areas of the body that will be treated by radiation), treatment is begun. Radiation is given 5 days a week for approximately 5 weeks at a radiation treatment center. The treatment takes just a few minutes each day and is completely painless. The typical radiation field used in the treatment of gastric cancer includes portions of the upper abdomen. In other words, it is designed to kill tumor cells in the area that the surgery was performed. Typical side effects include nausea and vomiting (though this should be less of a problems since the stomach has already been removed) and diarrhea.
Chemotherapy is defined as drugs that are used to kill tumor cells. The large advantage in using chemotherapy is that, since it is a medicine, is travels through the entire body. Hence, if some tumor cells have spread outside of what surgery or radiation can treat, they can potentially be killed by chemotherapy. Similar to radiation, some normal cells are damaged during treatment, resulting in side effects. The standard chemotherapy used in the treatment of gastric cancer is called 5-FU, coupled with another drug called leucovorin. This type of chemotherapy is delivered through the vein. Side effects from 5-FU and leucovorin include nausea, diarrhea, skin changes, and sores of the mouth. Although other chemotherapy drugs (cisplatin, oxaloplatin, epirubicin) are being investigated for the treatment of gastric cancer, 5-FU plus leucovorin remains the standard.
The value of radiation and chemotherapy was demonstrated in a large study just reported in 2001. They reported a much better outcome in patients with Stage IB or greater gastric cancer who were treated with radiation and chemotherapy after potentially curable surgery. This study sets the standard of care in the United States and is detailed as follows:
Surgery-to remove all of the cancer, as well as removal of the lymph nodes in the area of the stomach
Radiation-to the area of the upper abdomen, 5 days per week for 5 weeks. Radiation usually starts 4-6 weeks after surgery, to allow for recovery from surgery. Radiation may be delayed a few weeks if chemotherapy is started for a few week prior to combining the two treatments.
Chemotherapy-using 5-FU and leucovorin chemotherapy, given during the radiation and also after the radiation is completed. Sometimes chemotherapy is started for a few weeks prior to the start of radiation therapy
Follow-up testing for gastric cancer
Once a patient completes treatment for gastric cancer (including surgery +/- radiation and chemotherapy), he or she needs to be closely followed by his or her cancer physicians. This close follow-up is required for a couple of reasons. First, it needs to be insured that the patient recovers from the cancer treatment itself. This includes insuring the patient has no vomiting or diarrhea and has healed from surgery. Also, symptoms of "dumping syndrome" need to be addressed with dietary modifications. In addition, because of the removal of the stomach or a portion of the stomach, gastric cancer patients are prone to a certain type of anemia, resulting from not having enough vitamin B-12. This will be monitored for the patient's entire life, as this anemia does not usually occur until years after the surgery.
The other major reason a patient needs to be followed closely is to make sure their cancer does not recur. Recurrence can be detected using physical exam, repeat, periodic endoscopies, and CT scans. At first, patients will have follow-up visits and tests fairly often. The longer the patient is free of disease, the less often he or she will have to go for check-ups.

Fallopian Tube Cancer: The Basics

What is cancer of the fallopian tube(s)?
It is an abnormal growth of malignant cells (neoplasm, tumor) in one or both of a woman's fallopian tubes. The fallopian tubes are a pair of skinny ducts that transport a woman's eggs (ova) from her ovaries (where they are housed) to her uterus (aka "womb", where they are either fertilized by male sperm or discarded during menstruation). Typically, an egg is released from one of the ovaries into the adjacent fallopian tube once each month during ovulation, which occurs in reproductive-age women. The tube helps to move the egg along its journey to the uterus with small hair-like projections called cilia that line the tube's insides.
The tubes are named after a famous Italian physician named Gabriele Fallopio (1523–1562), who first described them.
What are the different types of fallopian tube cancer?
The vast majority (>95%) of fallopian tube cancers are papillary serous adenocarcinomas. Very occasionally, these tumors can be sarcomas (leiomyosarcomas) or transitional cell carcinomas.
How common is fallopian tube cancer?
Primary fallopian tube cancer is the rarest (only about 1%) of all gynecologic. The annual incidence of is about 3.6 per million women per year.
Who gets fallopian tube cancer?
The peak incidence is in women who are 60 - 64 years of age, but can continue to occur in women who are in their early- to mid- 80's. The diagnosis is more common in Caucasian women than in Black women, although the cause for this is not well understood.
What are the risk factors for fallopian tube cancer?
Given its rarity, the causes and risk factors for developing primary fallopian tube cancer are not clearly defined. There has been some association of the cancer with chronic infection and/or inflammation of the fallopian tubes (due to untreated sexually transmitted diseases, for example), although a cause-effect relationship has not been definitively established.
What are the symptoms of fallopian tube cancer?
The most common symptoms are vaginal bleeding, vaginal discharge, and/or pelvic pain. As a general rule, any vaginal bleeding in a postmenopausal women should be quickly and carefully evaluated. The vaginal discharge may be blood-tinged and does not appear to be infection-related and does not respond to antibiotic treatment. Finally, pelvic pain may occur because of trapped fluid blocking and distending the fallopian tube.
There is a syndrome called "hydrops tubae profluens" which consists of: 1) a pelvic mass, 2) profuse watery or honey-colored vaginal discharge, and 3) pelvic pain that essentially goes away upon sudden disappearance of the mass. Although this triad is rarely found in practice, it a classic diagnostic syndrome for fallopian tube disease.
How is fallopian tube cancer diagnosed?
Both in light of its rarity and the difficulty of seeing something abnormal growing on the inside of a tube, fallopian tube cancer can be a difficult diagnosis to make.
One of the most important steps in evaluating any patient with a gynecologic complaint is a proper pelvic examination. The healthcare provider (HCP) should examine the uterus, ovaries, fallopian tubes, and vagina. A p elvic mass is the most common physical finding, seen in about two-thirds of patients. Pelvic fluid (ascites) together with a mass is not as common, occurring in only about 15%.
Having said this, fallopian tube cancers are so rare that the finding of a pelvic mass is hardly enough to make a diagnosis of fallopian tube cancer. Furthermore, radiologic studies of the genitourinary and gastrointestinal tracts are not very helpful in making the diagnosis, either.
Microscopic analysis (as is done to look for cervical cancer, for example) of cervical and/or vaginal fluid has not in itself been a very reliable technique, with reports of only 40 - 60% of women with fallopian tube cancer having abnormal smears. A stronger tool is the combination of finding adenocarcinoma cells in cervical/vaginal fluid samples together with a negative in-depth exam and biopsy of the uterus (aka "dilatation and curettage").
Over the past 10 years or so, there has been increasing use of ultrasound, looking for the typical finding of a sausage-shaped mass with growths inside the fluid-filled center of the tube (so-called "cogwheel" appearance). The use of both transvaginal color and pulsed Doppler ultrasound seems to be an especially promising strategy.
Ultimately, most physicians feel that the diagnosis requires surgery to evaluate the tubes and obtain definitive tissue specimens.
* Serum levels of a marker called CA-125 can be abnormally high in patients with gynecologic diseases, both cancer and non-cancer types (ie: pelvic inflammatory disease, endometriosis, early pregnancy). Although this makes CA-125 pretty non-specific, checking a preoperative level is often recommended in a postmenopausal woman with a pelvic mass, if for no other reason than to establish a baseline value for later comparison and assessment of response to therapy.
Once it is diagnosed, how is fallopian tube cancer staged?
The following is adapted from the Federation of Gynecology and Obstetrics ( FIGO) staging system for fallopian tube carcinoma.
Stage 0
Carcinoma in situ (limited to tubal mucosa)
Stage I
Growth limited to the fallopian tubes
Stage IA
Growth limited to one tube with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites
Stage IB
Growth limited to both tubes with extension into submucosa and/or muscularis but not penetrating the serosal surface, no ascites
Stage 1C
Tumor either stage 1A or 1B with tumor extension through or onto the tubal serosa OR with ascites containing malignant cells OR with positive peritoneal washings
Stage II
Growth involving one or both fallopian tubes with pelvic extension
Stage IIA
Extension and/or metastasis to the uterus and/or ovaries
Stage IIB
Extension to other pelvic tissues
Stage IIC
Tumor either stage IIA or IIB AND with ascites containing malignant cells OR with positive peritoneal washing.
Stage III
Tumor involving one or both fallopian tubes with peritoneal implants outside of the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastases equals stage III. Tumor seems limited to the true pelvis with negative nodes but with histologically proved malignant extension to the small bowel or omentum
Stage IIIA
Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
Stage IIIB
Tumor involving one or both tubes with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Lymph nodes negative
Stage IIIC
Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes
Stage IV
Growth invading one or both fallopian tubes with distant metastases. If pleural effusion is present, there must be positive cytology to be stage IV. Parenchymal liver metastases equal stage IV
How is fallopian tube cancer treated?
As always, the optimal treatment regimen should ultimately be individualized as much as possible. It should take into account the patient's stage of disease, other medical history, and personal preference, among other things.
Surgery
As mentioned earlier, fallopian tube cancer is typically diagnosed with surgery. The new FIGO staging system requires an extensive surgical procedure very similar to the one used for ovarian cancer. It includes sampling of pelvic ascites fluid, pelvic and abdominal washings, transabdominal removal of uterus (hysterectomy), removal of both ovaries and fallopian tubes (bilateral salpingoo-ophorectomy), removal of some connective tissue folds (omentectomy), selective removal of pelvic lymph nodes (lymphadenectomy), and selective biopsies of the lining of the abdominal walls and organs (peritoneum).
In cases of very advanced disease, the goal of surgery is primarily to remove as much tumor bulk as safely possible (cytoreduction). Some surgeons also advocate performing a "second-look" surgery, in which a repeat abdominal surgery is done to look for residual or recurrent disease at a later time.
Radiation Therapy
According to a national retrospective study that compared postoperative chemotherapy to postoperative whole abdomen-pelvis radiation therapy, there was no significant difference in survival between the two treatment groups. However, this is not a randomized study, and so the ability to make conclusions from this data is limited. Unfortunately, there are no randomized trials comparing the efficacy of abdominopelvic radiotherapy and cisplatin-containing chemotherapy in the postoperative setting; given the rarity of this tumor, there likely never will.
For patients with more advanced disease, postoperative abdominopelvic radiation therapy can be recommended for patients with either microscopic or no residual disease in the upper abdomen and less than 1-cm of residual disease in the pelvis.
Chemotherapy
Fallopian tube cancer is fairly responsive to multi-drug regimens containing the agent cisplatin, as compared to non-cisplatin single agents or multi-drug regimens.
Hormonal Therapy
The role of hormonal treatment for fallopian tube cancer is not clear, although both medroxyprogesterone acetate and megestrol acetate have been used together with chemotherapy with varying degrees of success.
Combined Modality
The latest in combined modality approaches for advanced disease consists of cytoreductive surgery, post-surgical chemotherapy to reduce remaining tumor burden to microscopic levels, and possible post-chemotherapy abdominopelvic irradiation.
What is the prognosis?
Outcome is strongly dependent on stage, extent of postoperative residual disease, and treatment.
Fallopian tube carcinoma is a very rare form of gynecologic cancer and therefore, there are few patients to develop a general prognosis. A recent population based study (a way of combining all known cases to have larger numbers) found the 5-year survival (the percentage of patients alive 5 years after their diagnosis) to be 95% for patients with Stage I disease, 75% for stage II, 69% for stage III, and 45% for stage IV. In general, patients with fallopian tube cancer have a slightly better prognosis than those with ovarian cancer.

Cervical Cancer: The Basics

What is the cervix?
The cervix is the name for the lowest part of the uterus. The uterus is an organ that only women have, and it is where a baby grows and develops when a woman is pregnant. During pregnancy, the uterus has an enormous increase in size. When a woman is not pregnant, the uterus is a small, pear-shaped organ that sits between a woman's rectum and her bladder. The cervix connects the uterus with the birth canal (the vagina). The cervix can both be visualized and sampled by your doctor during a routine pelvic examination in his or her office.
What is cervical cancer?
Cervical cancer happens when cells in the cervix begin to grow out of control and can then invade nearby tissues or spread throughout the body. Large collections of this out of control tissue are called tumors. However, some tumors are not really cancer because they cannot spread or threaten someone's life. These are called benign tumors. The tumors that can spread throughout the body or invade nearby tissues are considered cancer and are called malignant tumors. Usually, cervix cancer is very slow growing although in certain circumstances it can grow and spread quickly.
Cancers are characterized by the cells that they originally form from. The most common type of cervical cancer is called squamous cell carcinoma; it comes from cells that lie on the surface of the cervix known as squamous cells. Squamous cell cervical cancer compromises about 80% of all cervical cancers. The second most common form is adenocarcinoma; it comes from cells that make up glands in the cervix. The percentage of cervical cancers that are adenocarcinomas has risen since the 1970s, although no one knows exactly why. About 3% to 5% of cervical cancers have characteristics of both squamous and adenocarcinomas and are called adenosquamous carcinomas. There are a few other very rare types like small cell and neuroendocrine carcinoma that are so infrequent they will not be discussed further.
Am I at risk for cervical cancer?
Cervical cancer is vastly more common in developing nations than it is in developed nations, particularly the United States. In the U.S., it is expected that 13,000 women will develop cervical cancer in 2002; and 4100 women will die of cervical cancer in 2002. This puts cervical cancer as the 12th most common cancer that women develop, and the 14th most common cause of cancer death for women in the U.S. However, cervical cancer is the 2nd most common cause of cancer death in developing nations, with about 370,000 new cases annually having a 50% mortality rate. There has been a 75% decrease in incidence and mortality from cervical cancer in developed nations over the past 50 years. Most of this decrease is attributed to the effective institution of cervical cancer screening programs in the wealthier nations.
Although there are several known risk factors for getting cervical cancer, no one knows exactly why one woman gets it and another doesn't. One of the most important risk factors for cervical cancer is infection with a virus called HPV (human papillomavirus). HPV is a sexually transmitted disease that is incredibly common in the population; one study showed that 43% of college age women were infected in a 3-year period. HPV is the virus that causes genital warts, but having genital warts doesn't necessarily mean you are going to get cervical cancer. There are different subtypes, or strains, of HPV. Only certain subtypes are likely to cause cervical cancer, and the subtypes that cause warts are unlikely to cause a cancer. Often, infection with HPV causes no symptoms at all, until a woman develops a pre-cancerous lesion of the cervix. It should be stressed that only a very small percentage of women who have HPV will develop cervical cancer; so simply having HPV doesn't mean that you will get sick. However, almost all cervical cancers have evidence of HPV virus in them, so infection is a major risk factor for developing it.
Because infection with a sexually transmitted disease is a risk factor for cervical cancer, any risk factors for developing sexually transmitted diseases are also risk factors for developing cervical cancer. Women who have had multiple male sexual partners, began having sexual intercourse at an early age, or have had male sexual partners who are considered high risk (meaning that they have had many sexual partners and/or began having sexual intercourse at an early age) are at a higher risk for developing cervical cancer. Also, contracting any other sexually transmitted diseases (like herpes, gonorrhea, syphilis, or chlamydia) increases a woman's risk. HIV infection is another risk factor for cervical cancer, but it may be so for a slightly different reason. It seems that any condition that weakens your immune system also increases your risk for developing cervical cancer. Conditions that weaken your immune system include HIV, having had an organ transplantation, and Hodgkin's disease. There also seems to be slightly increased risk of developing cervical cancer if your male sexual partners are uncircumcised.
Another important risk factor for developing cervical cancer is smoking. Smokers are at least twice as likely as non-smokers to develop cervix tumors. Smoking may also increase the importance of the other risk factors for cancer. Finally, being in a low socioeconomic group seems to increase your likelihood for developing and dying from cervical cancer. This may be because of increased smoking rates, or perhaps because there are more barriers to getting annual screening exams. Cervical cancer is one of the few cancers that affects young women (in their twenties and even their teens), so no one who is sexually active is really too young to begin screening. Also, the risk for cervical cancer doesn't ever decline, so no one is too old to continue screening. Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get cervical cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease.
How can I prevent cervical cancer?
Right now, the most important thing any woman can do to decrease her risk of dying from cervix cancer is to undergo regular Pap testing. Pap tests will be discussed further in the next section, but the reason that women have had such a drastic drop in cervical cancer cases and deaths in this country has been because of the Pap test and annual screening.
In terms of prevention, the next most important thing to do is to modify the risk factors that you have control over. Don't start smoking, and if you are already a smoker, it is time to quit. Women can limit their numbers of sexual partners, and delay the onset of sexual activity. Unfortunately, condoms do not protect you from developing HPV, so even though they can protect you from other sexually transmitted diseases and HIV, they cannot help lower your risk for developing cervical cancer.
Many people are interested in preventing cervical cancer with vitamins or diets. Studies looking at beta-carotene and folic acid for preventing cervical cancer have shown no benefit. Some people think that anti-oxidants (like vitamin A and vitamin E) may play a role in cervical cancer prevention, but there is currently no convincing data that would suggest so. Further studies need to be performed before any nutritional recommendations can be made regarding cervix cancer prevention.
Finally, there is hope that one day there will be an effective vaccine against HPV. If we were able to stop HPV infection, then rates of cervical cancer should plummet. This is an especially appealing strategy in third-world nations that don't have the resources to implement Pap screening like developed countries. However, an effective vaccine does not currently exist. The future may show this idea bear fruit, but for right now, the most important thing anyone can do to prevent cervical cancer is to get their annual screening exams with Pap tests.
What screening tests are available?
Cervical cancer is considered a preventable disease. It usually takes a very long time for pre-cancerous lesions to progress to invasive cancers and we have effective screening methods that can detect pre-cancerous lesions that can generally be cured without serious side effects. Effective screening programs in the United States have led to the drastic decline in the numbers of cervical cancer deaths in the last 50 years. For women who do end up with cervical cancer in developed nations, 60% of them either have never been screened or haven't been screened in the last five years. The importance of regular cervical cancer screening cannot be overstated.
The current hallmark of cervical cancer screening is the Pap test. Pap is short for Papanicolaou, the inventor of the test, who published a breakthrough paper back in 1941. A Pap test is easily performed in your doctor's office. During a pelvic examination, your doctor uses a wooden spatula and/or a brush to get samples of cervical cells. These cells are placed on a slide, fixed, and sent to a laboratory where an expert in examining cells under a microscope can look for cancerous changes. Many women find the exam uncomfortable, but rarely painful. Depending on the results of the test, your doctor may need to perform further examinations.
Although the Pap test is highly effective, it isn't a perfect test. Sometimes, the test may miss cells that have potential to become an invasive cancer. The test shouldn't be performed when you are menstruating; and if collection goes perfectly, even the best laboratories can miss abnormal cells. This is why women need to have the tests performed on a regular basis - it may miss abnormal cells one year, but it is unlikely to miss anything two years in a row.
Women should begin having yearly Pap tests done at the onset of sexual activity, or the age 18 - whichever comes first. Most women should continue to have Pap tests done on a yearly basis; however, there is a subset of women who could get testing done every two or even every three years with the agreement of their physician. Women in low risk groups (monogamous with monogamous partners) who have had three normal Pap tests may want to discuss the option of getting the tests done every two or three years. However, after having a new sexual partner, these women need to go back to yearly Pap testing. Women who have had a hysterectomy still need to get examined with a Pap test. Women who have had a "subtotal or supracervical" hysterectomy still have a cervix, and need to continue Pap testing annually. Women who have had a total hysterectomy need to have the tissue in their vaginas examined by a Pap test every 3 to 5 years. Women who are post-menopausal still need Pap exams, but the frequency will depend on their physician's understanding of their particular health needs.
A new screening modality for cervical cancer that may become important in the future is HPV testing. HPV testing can theoretically find the vast majority of women who are at risk for developing cervical cancer. With modern DNA analysis, we have the ability to tell which subtype, or strain, of HPV a person is infected with. The subtype of HPV predicts how likely it is to lead to a cervical cancer. Some of the advantages of HPV testing are that it can be done at home, in private, by a woman collecting a sample herself and sending it to a laboratory via the mail. Also, there is less technical expertise required to correctly run an HPV test than a Pap test. This cuts down on errors and cost. However, the test isn't perfect because the majority of women with HPV will not go on to have cervical cancer, and a positive test result creates the need for expensive and often unnecessary follow-up testing. Although this test is not in current use by itself for cervical cancer screening, in the future, HPV testing may one day replace Pap testing for primary cervical cancer screening. Another possible benefit of HPV testing comes coupling the Pap test with an HPV test, to pick up even more cases of pre-cancerous lesions. Talk to your doctor about your options and the availability of HPV testing in your area.
What are the signs of cervical cancer?
Unfortunately, the early stages of cervical cancer usually do not have any symptoms. This is why it is important to have screening Pap tests. As a tumor grows in size, it can produce a variety of symptoms including:
abnormal bleeding (including bleeding after sexual intercourse, in between periods, heavier/longer lasting menstrual bleeding, or bleeding after menopause)
abnormal vaginal discharge (may be foul smelling)
pelvic or back pain
pain on urination
blood in the stool or urine
Many of these symptoms are non-specific, and could represent a variety of different conditions; however, your doctor needs to see you if you have any of these problems.
How is cervical cancer diagnosed and staged?
The most common reason for your doctor to pursue the diagnosis of cervical cancer is if you have an abnormal Pap test. Pap tests exist to find pre-cancerous lesions in your cervix. A pre-cancerous lesion means that there are abnormal appearing cancer cells, but they haven't invaded past a tissue barrier in your cervix; thus a pre-cancerous lesion cannot spread or harm you. However, if left untreated, a pre-cancerous lesion can evolve to an invasive cancer. Pap tests are reported as no abnormal cells, abnormal cells of undetermined significance, low risk abnormal cells or high risk abnormal cells. Depending on your specific case, your doctor will decide how to proceed.
A report of no abnormal cells equates to a negative test, meaning you simply need to follow-up in one year. The abnormal cells of undetermined significance can be handled in three different ways. Women can either get a repeat Pap test in 4-6 months, they can get HPV testing, or they can be referred for colposcopy. Colposcopy is a procedure done during a pelvic exam with the aide of a colposcope, which is like a microscope. By using acetic acid on the cervix and examining it with a colposcope, your doctor can look for abnormal areas of your cervix. Then, the most abnormal areas can be biopsied. A biopsy is the only way to know for sure if you have cancer, because it allows your doctors to get cells that can be examined under a microscope. Once the tissue is removed, a doctor known as a pathologist will review the specimen. Colposcopy is uncomfortable, but not painful, and can be done in your gynecologist's office. Your doctor will decide how to proceed with the workup of a Pap test showing abnormal cells of undetermined significance depending on the details of your case. If repeat Pap tests are not normal, then you will be referred for colposcopy. If you test positive for HPV, you will be referred for colposcopy. Also, sometimes abnormal cells of undetermined significance look a little too worrisome for cancer and get a slightly different category that means you need to go for colposcopy right away. Generally, most patients with low risk abnormal cells, or high risk abnormal cells will be immediately referred for colposcopy. If you are pregnant, an adolescent, HIV positive, or post-menopausaul, your doctor may have slightly different recommendations. Also, sometimes your Pap test will show cells that look abnormal but could have come from higher in your uterus. There is a chance that if this happens, you will need to have your uterine lining sampled. Talk to your doctor about your Pap test results, and what you need to do next after an abnormal Pap smear.
If you are having symptoms (bleeding/discharge) from a cervical cancer, then it can probably be visualized during a pelvic exam. Any time your doctor can see a cervical tumor on pelvic exam, it will be immediately biopsied. When abnormal appearing tissue is noticed during a colposcopy, then it needs to be biopsied as well. There are a few different ways to do a biopsy. A punch biopsy, removes a small section of the cervix. A LEEP (loop electrosurgical excision procedure) is another method to do a biopsy where a thin slice of the cervix is removed. Finally, sometimes a conization or cone biopsy is performed. A cone biopsy removes a thicker section of the cervix, and allows the pathologist to see if malignant cells have invaded underneath the surface. The cone biopsy has the added value of sometimes being able to cure a pre-cancerous lesion that is localized to a small area. Treatments for cervical cancer and pre-cancerous lesions will be discussed further in the next section.
In order to guide treatment and offer some insight into prognosis, cervical cancer is staged into different groups. There are a few different staging systems, but the most popular one for cervical cancer is the FIGO system (International Federation of Gynecologists and Obstetricians). The FIGO system is a clinical staging system which means that the cancer is staged by a doctor's physical examination and the results of a biopsy. The FIGO staging system is for invasive cervical cancers, not pre-cancerous lesions. A simplified version of the FIGO staging system is:
Stage IA - microscopic cancer confined to the uterus
Stage IB - cancer visible by the naked eye confined to the uterus
Stage II - cervical cancer invading beyond the uterus but not to the pelvic wall or lower 1/3 of the vagina
Stage III - cervical cancer invading to the pelvic wall and/or lower 1/3 of the vagina and/or causing a non-functioning kidney
Stage IVA - cervical cancer that invades the bladder or rectum, or extends beyond the pelvis
Stage IVB - distant metastases
Because the physical exam is so important for staging a cervical cancer, your doctors may want to do the most thorough examination possible while you are under anesthesia. Another important test is called intravenous pyelography (IVP), which takes an x-ray of your kidneys after you get a dye load, so that your kidney function can be evaluated. Other times, your doctors will want the results of other radiologic tests to better characterize your specific cancer. Tests like CAT scans (3-D x-rays) or MRIs (like a CAT scans but done with magnets) can examine the cervix and localized lymph nodes. X-rays may be taken of your bones and/or chest. Sometimes, your doctors may want to have a look in your bladder and do a cystoscopy, in which a lighted scope is inserted through your urethra into your bladder. You may get also get a protosigmoidoscopy, which uses a lighted scope to examine your rectum and colon. Each patient is an individual so the specific tests people get will vary; but overall, your doctors want to know as much about your particular tumor as possible so that they can plan the best available treatments.
What are the treatments for cervical cancer?
Pre-cancerous lesionsWomen who have pre-cancerous lesions demonstrated on biopsy after colposcopy have a few different options how to proceed. A woman may decide on a specific option depending on whether or not she plans to have children in the future, her current health status and life expectancy, and her concerns about the future and the possibility of having a cancer come back. You should talk to your doctor about you fears, concerns and preferences. Sometimes, women with low grade lesions may choose to not have any further treatment, especially if the biopsy removed the entire lesion. If you decide to do this, you will need frequent pelvic exams and Pap tests. There are a few different ways to remove pre-cancerous lesions without removing the entire uterus (and thus preserving a woman's ability to have a baby in the future). Women can have cryosurgery (freezing off the abnormal lesion), a LEEP (the same type of electrosurgical procedure used for biopsies), a conization (the thicker type of biopsy that gets tissue under the surface), or have the cells removed with a laser. Your doctor can discuss the benefits and drawbacks of each of these modalities. Women who do not have any plans to have children in the future and are particularly worried about their chances of getting an invasive cancer may elect to have a hysterectomy (a surgery that removes your uterus and cervix). This procedure is much more invasive than any of the previous treatment modalities, but can provide peace of mind to women finished with childbearing.
SurgerySurgery is generally only employed in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible, but it usually isn't used unless all of the cancer can be removed at the time of surgery. Cancers that have a high chance of already being in the lymph nodes are not treated with surgery (lymph nodes are small, pea-sized pieces of tissue that filter and clean lymph, a liquid waste product). There are a few different types of surgeries that can be performed. The earliest stage IA tumors can sometimes be treated with only a hysterectomy (removal of the uterus and cervix). Bigger stage IA, stage IB, and occasionally stage IIA tumors can be treated with more extensive hysterectomies coupled with lymphadenectomies (procedures that remove lymph nodes in the pelvis). Depending on the amount of disease, your surgeon may have to remove tissues around the uterus, as well as part of the vagina and the fallopian tubes. One of the benefits of surgery in young women is that sometimes their ovaries can be left, so that they do not go through menopause at an early age. Higher stage disease is usually treated with radiation and chemotherapy, but sometimes surgery is employed if cervical cancer comes back after it has already been treated. A pelvic exeneration is reserved for recurrent cervical cancers. A pelvic exeneration is a drastic surgery in which the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon are removed. This surgery is not commonly employed, but is occasionally used for recurrent cancers.
Radiotherapy
Radiation therapy has proven very effective in treating cervical cancer. Radiation therapy uses high energy rays (similar to x-rays) to kill cancer cells. Radiation therapy is another option besides surgery for early stage cervical cancer; and when advanced stage cervical cancer needs to be treated, it is usually done with radiation therapy. Surgery and radiation have been shown to be equivalent treatments for early stage cervical cancers, and radiation helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation has the benefit of being able to treat all of the disease in the radiation field; thus lymph nodes can be treated as well as the primary tumor in the course of the same treatment.
Radiation therapy for cervical cancer either comes from an external source (external beam radiation) or an internal source (brachytherapy). External beam radiation therapy requires patients to come in 5 days a week for up 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. With all cervical cancers above stage IB, the standard approach with radiotherapy is to use external beam radiation coupled with internal brachytherapy. Brachytherapy (also called intracavitary irradiation) allows your radiation oncologist to "boost" the radiation dose to the tumor site. This provides an added impact to the tumor, while sparing your normal tissues. This is done by inserting a hollow, metal tube with two egg shaped cartridges into your vagina. Then a small radioactive source is placed in the tube and cartridges. A computer has calculated how long the source needs to be there, but usually for what is called low dose rate (LDR) brachytherapy, you will need to have the source in for a few days. This procedure is done in the hospital, because for those few days you have to remain in bed. Another type of brachytherapy, called high dose rate (HDR) brachytherapy, uses more powerful sources that only stay in for a few minutes. Although this option usually sounds better to patients, there is debate as to which type is more effective and some institutions favor one over the other. Talk to your radiation oncologist about your options and their opinion as to HDR versus LDR for cervical cancer treatment.
Another use of radiation is for palliation - meaning that patients with very advanced cases of cervical cancer are treated with the intent of easing their pain or symptoms, rather than trying to cure their disease. Sometimes, women with early stage cancers get surgery, but after the results of the surgery, it becomes clear that they will need radiation as well. Finally, radiation is often combined with chemotherapy, and depending on your case your doctor will decide on the best possible treatment arrangement for your lifestyle and wishes.
Chemotherapy
Despite the fact that tumors are removed by surgery or treated with radiation, there is always a risk of recurrence because there may be microscopic cancer cells left in the body. In order to decrease a patient's risk of a recurrence, they are often offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Practically all patients who are in good medical condition and receiving radiation for stage IIA or higher cervical cancer will be offered chemotherapy in addition to their radiation. It may even be offered for earlier stage patients depending on the particulars of their case. There have been many studies that demonstrate the usefulness of adding chemotherapy to radiation in terms of decreasing mortality from cervical cancer.
There are many different chemotherapy drugs, and they are often given in combinations for a series of months. Depending on the type of chemotherapy regimen you receive, you may get medication every week or few weeks; and you usually have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein. The most commonly employed regimens use a drug called Cisplatin, but other drugs like 5-FU, Hydroxyurea, Ifosfamide, and Paclitaxel may also be employed. There are advantages and disadvantages to each of the different regimens that your gynecologic oncologist or medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.
Follow-up testing
Once a patient has been treated for cervix cancer, they need to be closely followed for a recurrence. At first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will have to go for checkups. Your doctor will tell you when he or she wants follow-up visits, Paps and x-rays or scans depending on your case. Your doctor will also do pelvic exams regularly during your office visits. It is very important that you let your doctor know about any symptoms you are experiencing and that you keep all of your follow-up appointments.
Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your doctor about participating in clinical trials in your area.
This article is meant to give you a better understanding of cervical cancer. Use this knowledge when meeting with your physician, making treatment decisions, and continuing your search for information. You can learn more about cervical cancer on OncoLink through the related links to the left.

Breast Cancer: The Basics

What is the breast?
The breast is a collection of glands and fatty tissue that lies between the skin and the chest wall. The glands inside the breast produce milk after a woman has a baby. Each gland is also called a lobule, and many lobules make up a lobe. There are 15 to 20 lobes in each breast. The milk gets to the nipple from the glands by way of tubes called ducts. The glands and ducts get bigger when a breast is filled with milk, but the tissue that is most responsible for the size and shape the breast is the fatty tissue. There are also blood vessels and lymph vessels in the breast. Lymph is a clear liquid waste product that gets drained out of the breast into lymph nodes. Lymph nodes are small, pea-sized pieces of tissue that filter and clean the lymph. Most lymph nodes that drain the breast are under the arm in what is called the axilla.
What is breast cancer?
Breast cancer happens when cells in the breast begin to grow out of control and can then invade nearby tissues or spread throughout the body. Large collections of this out of control tissue are called tumors. However, some tumors are not really cancer because they cannot spread or threaten someone's life. These are called benign tumors. The tumors that can spread throughout the body or invade nearby tissues are considered cancer and are called malignant tumors. Theoretically, any of the types of tissue in the breast can form a cancer, but usually it comes from either the ducts or the glands. Because it may take months to years for a tumor to get large enough to feel in the breast, we screen for tumors with mammograms, which can sometimes see disease before we can feel it.
Am I at risk for breast cancer?
Breast cancer is the most common malignancy affecting women in North America and Europe. Every woman is at risk for breast cancer. Close to 200,000 cases of breast cancer were diagnosed in the United States in 2001. Breast cancer is the second leading cause of cancer death in American women behind lung cancer. The lifetime risk of any particular woman getting breast cancer is about 1 in 8 although the lifetime risk of dying from breast cancer is much lower at 1 in 28.
Risk factors for breast cancer can be divided into those that you cannot change and those that you can change. Some factors that increase your risk of breast cancer that you cannot alter include being a woman, getting older, having a family history (having a mother, sister, or daughter with breast cancer doubles your risk), having a previous history of breast cancer, having had radiation therapy to the chest region, being Caucasian, getting your periods young (before 12 years old), having your menopause late (after 50 years old), never having children or having them when you are older than 30, and having a genetic mutation that increases your risk. Genetic mutations for breast cancer have become a hot topic of research lately. Between 3% to 10% of breast cancers may be related to changes in either the gene BRCA1 or the gene BRCA2. Women can inherit these mutations from their parents and it may be worth testing for either mutation if a woman has a particularly strong family history of breast cancer (meaning multiple relatives affected, especially if they are under 50 years old when they get the disease). If a woman is found to carry either mutation, she has a 50% chance of getting breast cancer before she is 70. Family members may elect to get tested to see if they carry the mutation as well. If a woman does have the mutation, she can get more rigorous screening or even undergo preventive (prophylactic) mastectomies to decrease her chances of contracting cancer. The decision to get tested is a highly personal one that should be discussed with a doctor who is trained in counseling patients about genetic testing. For more information on genetic testing, see Let the Patient Beware: Implications of Genetic Breast-Cancer Testing, Psychological Issues in Genetic Testing for Breast Cancer, and To Test or Not to Test? Genetic Counseling Is the Key.
Certain factors which increase a woman's risk of breast cancer can be altered including taking hormone replacement therapy (long term use of estrogens with progesterone for menopause symptoms slightly increases your risk), taking birth control pills (a very slight increased risk that disappears in women who have stopped them for over 10 years), not breastfeeding, drinking 2 to 5 alcoholic drinks a day, being overweight (especially after menopause), and not exercising. All of these modifiable risk factors are not nearly as important as gender, age, and family history, but they are things that a woman can control that may reduce her chances of developing a breast malignancy. Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get breast cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease. For further information about breast cancer risk factors, see Breast Cancer Risk Assessment Tool,and Risk Factors and Breast Cancer.
How can I prevent breast cancer?
The most important risk factors for the development of breast cancer cannot be controlled by the individual. There are some risk factors that are associated with an increased risk, but there is not a clear cause and effect relationship. In no way can strong recommendations be made like the cause and effect relationship seen with tobacco and lung cancer. There are a few risk factors that may be modified by a woman that potentially could influence the development of breast cancer. If possible, a woman should avoid long-term hormone replacement therapy, have children before age 30, breastfeed, avoid weight gain through exercise and proper diet, and limit alcohol consumption to 1 drink a day or less. For women already at a high risk, their risk of developing breast cancer can be reduced by about 50% by taking a drug called Tamoxifen for five years. Tamoxifen has some common side effects (like hot flashes and vaginal discharge), which are not serious and some uncommon side effects (like blood clots, pulmonary embolus, stroke, and uterine cancer) which are life threatening. Tamoxifen isn't widely used for prevention, but may be useful in some cases. There are limited data suggesting that vitamin A may protect against breast cancer but further research is needed before it can be recommended for prevention. Other things being investigated include phytoestrogens (naturally occurring estrogens that are in high numbers in soy), vitamin E, vitamin C, and other drugs. Further testing of these substances is also needed before they can be recommended for breast cancer prevention. Right now, the most important thing any woman can do to decrease her risk of dying from breast cancer is to have regular mammogram screening, learn how to perform breast self exams, and have a regular physical examination by their physician. For more information on breast cancer prevention, see NCI/PDQ Physician Statement: Prevention of breast cancer.
What screening tests are available?
The earlier that a breast cancer is found, the more likely it is that treatment can be curable. For this reason, we screen for breast cancer using mammograms, clinical breast exams, and breast self-exams. Screening mammograms are simply x-rays of each breast. The breast is placed between two plates for a few seconds while the x-rays are taken. If something appears abnormal, or better views are needed, magnified views or specially angled films are taken during the mammogram. Mammograms often detect tumors before they can be felt and they can also identify tiny specks of calcium that could be an early sign of cancer. Regular screening mammograms can decrease the mortality of breast cancer by 30%. The majority of breast cancers are associated with abnormal mammographic findings. Woman should get a yearly mammogram starting at age 40 (although some groups recommend starting at 50), and women with a genetic mutation that increases their risk or a strong family history may want to begin even earlier.
Between the ages of 20 and 39, every woman should have a clinical breast exam every 3 years; and after age 40 every woman should have a clinical breast exam done each year. A clinical breast exam is an exam done by a health professional to feel for lumps and look for changes in the size or shape of your breasts. During the clinical breast exam, you can learn how to do a breast self-exam. Every woman should do a self breast exam once a month, about a week after her period ends. If you find any changes in your breasts, you need to contact your doctor. About 15% of tumors are felt but cannot be seen by regular mammographic screening.
There are some experimental screening modalities that are currently being studied. These include MRI, ductal lavage, ultrasound, optical tomography, PET scan, and digital mammograms. For more information on these experimental techniques, see Advanced Breast Imaging, Penn Leads International Study on Breast Cancer Detection, and Komen Foundation Focuses Attention on the Need for Improved Breast Imaging and Early Detection Technologies: OncoLink Talks with President and CEO Susan Braun and Director of Grants Anice Thigpen, PhD
What are the signs of breast cancer?
Unfortunately, the early stages of breast cancer may not have any symptoms. This is why it is important to follow screening recommendations. As a tumor grows in size, it can produce a variety of symptoms including:
lump or thickening in the breast or underarm
change in size or shape of the breast
nipple discharge or nipple turning inward
redness or scaling of the skin or nipple
ridges or pitting of the breast skin
If you experience these symptoms, it doesn't necessarily mean you have breast cancer, but you need to be examined by a doctor.
How is breast cancer diagnosed and staged?
Once a patient has symptoms suggestive of a breast cancer or an abnormal screening mammogram, they will usually be referred for a diagnostic mammogram. A diagnostic mammogram is another set of x-rays; however, it is more complete with close ups on the suspicious areas. Sometimes, particularly if your doctors think that you may have a cyst or you are young and have dense breasts, you may be referred for an ultrasound. An ultrasound uses high-frequency sound waves to outline the suspicious areas of the breast. It is painless and can often distinguish between benign and malignant lesions.
Depending on the results of the mammograms and/or ultrasounds, your doctors may recommend that you get a biopsy. A biopsy is the only way to know for sure if you have cancer, because it allows your doctors to get cells that can be examined under a microscope. There are different types of biopsies; they differ on how much tissue is removed. Some biopsies use a very fine needle, while others use thicker needles or even require a small surgical procedure to remove more tissue. Your team of doctors will decide which type of biopsy you need depending on your particular breast mass.
Once the tissue is removed, a doctor known as a pathologist will review the specimen. The pathologist can tell if it is cancer or not; and if it is cancerous, then the pathologist will characterize it by what type of tissue it arose from, how abnormal it looks (known as the grade), whether or not it is invading surrounding tissues, and if the entire lump was excised, the pathologist can tell if there are any cancer cells left at the borders (also known as the margins). The pathologist will also test the cancer cells for the presence of estrogen and progesterone receptors as well as a receptor known as
HER-2/neu. The presence of estrogen and progesterone receptors is important because cancers that have those receptors can be treated with hormonal therapies. HER-2/neu expression may also help predict outcome. There are also some therapies directed specifically at tumors dependent on the presence of HER-2/nue.
In order to guide treatment and offer some insight into prognosis, breast cancer is staged into five different groups. This staging is done in a limited fashion before surgery taking into account the size of the tumor on mammogram and any evidence of spread to other organs that is picked up with other imaging modalities; and it is done definitively after a surgical procedure that removes lymph nodes and allows a pathologist to examine them for signs of cancer. The staging system is somewhat complex, but here is a simplified version of it:Stage 0 (called carcinoma in situ)
Lobular carcinoma in situ (LCIS) refers to abnormal cells lining a gland in the breast. This is a risk factor for the future development of cancer, but this is not felt to represent a cancer itself.
Ductal carcinoma in situ (DCIS) refers to abnormal cells lining a duct. Women with DCIS have an increased risk of getting invasive breast cancer in that breast. Treatment options are similar to patients with Stage I breast cancers.
Stage I: early stage breast cancer where the tumor is less that 2 cm across and hasn't spread beyond the breast
Stage II : early stage breast cancer where the tumor is either less than 2 cm across and has spread to the lymph nodes under the arm; or the tumor is between 2 and 5 cm (with or without spread to the lymph nodes under the arm); or the tumor is greater than 5 cm and hasn't spread outside the breast
Stage III: locally advanced breast cancer where the tumor is greater than 5 cm across and has spread to the lymph nodes under the arm; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast
Stage IV: metastatic breast cancer where the cancer has spread outside the breast to other organs in the body
Depending on the stage of your cancer, your doctor may want additional tests to see if you have metastatic disease. If you have a stage III cancer, you will probably get a chest x-ray, CT scan and bone scan to look for metastases. Each patient is an individual and your doctors will decide what is necessary to adequately stage your cancer.
What are the treatments for breast cancer?
Surgery
Almost all women with breast cancer will have some type of surgery in the course of their treatment. The purpose of surgery is to remove as much of the cancer as possible, and there are many different ways that the surgery can be carried out. Some women will be candidates for what is called breast conservation therapy (BCT). In BCT, surgeons perform a lumpectomy which means they remove the tumor with a little bit of breast tissue around it but do not remove the entire breast. BCT always needs to be combined with radiation therapy to make it an option for treating breast cancer. At the time of the surgery, the surgeon may also dissect the lymph nodes under the arm so the pathologist can review them for signs of cancer. Some patients will have a sentinel lymph node biopsy procedure first to determine if a formal lymph node dissection is required. Sometimes, the surgeon will remove a larger part (but not the whole breast), and this is called a segmental or partial mastectomy. This needs to be combined with radiation therapy as well. In early stage cancers (like stage I and II), BCT is as effective as removal of the entire breast via mastectomy. Most patients with DCIS that have a lumpectomy are treated with radiation therapy to prevent the local recurrence of DCIS (although some of these DCIS patients may be candidates for close observation after surgery). The advantage of BCT is that the patient will not need a reconstruction or prosthesis to appear like she did before the procedure.
More advanced breast cancers are usually treated with a modified radical mastectomy. Modified radical mastectomy means removing the entire breast and dissecting the lymph nodes under the arm. Patients with DCIS that have a mastectomy do not need to have the lymph nodes removed from under the arm. Some patients are candidates for BCT but choose modified radical mastectomy for personal reasons. Your surgeon can discuss your options and the pros and cons of either procedure. Most women who have modified radical mastectomies choose to undergo a reconstruction. There are many different procedures for creating a new breast mound, and you should talk to your plastic surgeon before your surgery to discuss your options and decide on how you would like to proceed. For more information on breast reconstruction, see Breast Reconstructive Surgery Options.
Chemotherapy
Despite the fact that the tumors are removed by surgery, there is always a risk of recurrence because there may be microscopic cancer cells that have spread to distant sites in the body. In order to decrease a patient's risk of recurrence, many breast cancer patients are offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. The higher the stage of cancer you have, the more important it is that you receive chemotherapy; however, even stage I patients may benefit from chemotherapy in certain cases. In early stage patients, the risk of recurrence may be small, and thus the benefits of the chemotherapy are even smaller. However, the option to receive chemotherapy should be offered to most patients with breast cancer and they can decide if the potential benefits of chemotherapy outweigh its side effects in their own particular case.
There are many different chemotherapy drugs, and they are usually given in combinations for 3 to 6 months after you receive your surgery. Depending on the type of chemotherapy regimen you receive, you may get medication every 3 or 4 weeks; and you may have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein. Two of the most common regimens are AC (doxorubicin and cycolphosphamide) for 3 months or CMF (cyclophosphamide, methotrexate, and fluorouracil) for 6 months. There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.
Sometimes patients have a recurrence of their cancer, or present in stage IV with disease outside of their breast. These patients will all need chemotherapy, and a variety of different agents may be tried until a response is achieved. Sometimes we give chemotherapy before surgery, and this is called neoadjuvant chemotherapy. This is usually reserved for very advanced cancers that need to be shrunken before they can be operated on.
Radiotherapy
Breast cancer commonly receives radiation therapy. Radiation therapy uses high energy rays (similar to x-rays) to kill cancer cells. It comes from an external source, and it requires patients to come in 5 days a week for up to 6 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. Radiation therapy is used in all patients who receive breast conservation therapy (BCT). It is also recommended for patients after a mastectomy who had large tumors, lymph node involvement, or close/positive margins after the surgery. Radiation is important in reducing the risk of local recurrence and is often offered in more advanced cases to kill tumor cells that may be living in lymph nodes. Your radiation oncologist can answer questions about the utility, process, and side effects of radiation therapy in your particular case.
Hormonal Therapy
When the pathologist examines your tumor specimen, he or she finds out if the tumor is expressing estrogen and progesterone receptors. Patients whose tumors express estrogen receptors are candidates for therapy with an estrogen blocking drug called Tamoxifen. Tamoxifen is taken by pill form for 5 years after your surgery. This drug has been shown to drastically reduce your risk of recurrence if your tumor expresses estrogen receptors. However, there are side effects commonly associated with Tamoxifen including weight gain, hot flashes and vaginal discharge that patients may be bothered by. There are also very uncommon side effects like blood clots, strokes, or uterine cancer that may scare patients from choosing to take it. You need to remember that your chances of having a recurrence of your cancer are usually higher than your chances of having a serious problem with Tamoxifen, but the decision to undergo hormonal therapy is a personal one that you should make with your doctor. There are also newer drugs, called aromatase inhibitors that act by decreasing your body's supply of estrogen; these drugs are reserved for patients who have already gone through menopause. Talk to your doctors about these new therapies.
Biologic Therapy
The pathologist also examines your tumor for the presence of HER-2/neu overexpression. HER-2/neu is a receptor that some breast cancers express. If your cancer expresses it, you usually have a higher chance of having your tumor recur after surgery. A compound called Herceptin (or Trastuzumab) is a substance that blocks this receptor and helps stop the breast cancer from growing. Some patients are candidates for this medicine. Talk to your medical oncologist to see if Herceptin is right for you.
Follow-up testing
Once a patient has been treated for breast cancer, they need to be closely followed for a recurrence. At first, you will have follow-up visits every 3-4 months. The longer you are free of disease, the less often you will have to go for checkups. After 5 years, you could see your doctor once a year. You should have a mammogram of the treated and untreated breasts every year. Because having had breast cancer is a risk factor for getting it again, having your mammograms done every year is extremely important. If you are taking Tamoxifen, it is important that you get a pelvic exam each year and report any abnormal vaginal bleeding to your doctor.
Clinical trials are extremely important in furthering our knowledge of this disease. It is though clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your doctor about participating in clinical trials in your area.
This article is meant to give you a better understanding of breast cancer. Use this knowledge when meeting with your physician, making treatment decisions, and continuing your search for information. You can learn more about breast cancer on OncoLink through the related links mentioned in this article.