Jennifer D.

Manuel Defining Cancer

BSN-4G

Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. Most cancers are named for the organ or type of cell in which they start - for example, cancer that begins in the colon is called colon cancer; cancer that begins in basal cells of the skin is called basal cell carcinoma. Cancer types can be grouped into broader categories. The main categories of cancer include: Carcinoma - cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma - cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia - cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and myeloma - cancers that begin in the cells of the immune system. Central nervous system cancers - cancers that begin in the tissues of the brain and spinal cord. Origins of Cancer All cancers begin in cells, the body's basic unit of life. To understand cancer, it's helpful to know what happens when normal cells become cancer cells. The body is made up of many types of cells. These cells grow and divide in a controlled way to produce more cells as they are needed to keep the body healthy. When cells become old or damaged, they die and are replaced with new cells. However, sometimes this orderly process goes wrong. The genetic material (DNA) of a cell can become damaged or changed, producing mutations that affect normal cell growth and division. When this happens, cells do not die when they should and new cells form when the body does not need them. The extra cells may form a mass of tissue called a tumor.

Not all tumors are cancerous; tumors can be benign or malignant. Benign tumors aren't cancerous. They can often be removed, and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Malignant tumors are cancerous. Cells in these tumors can invade nearby tissues and spread to other parts of the body. The spread of cancer from one part of the body to another is called metastasis. Some cancers do not form tumors. For example, leukemia is a cancer of the bone marrow and blood.

Cancer Statistics A report from the nation's leading cancer organizations shows that rates of new diagnoses and rates of death from all cancers combined declined significantly in the most recent time period for men and women overall and for most racial and ethnic populations in the United States. (Read more about theAnnual Report.) Estimated new cases and deaths from cancer in the United States in 2010: New cases: 1,529,560 (does not include nonmelanoma skin cancers) Deaths: 569,490 Cancer Staging

Key Points Staging describes the extent or severity of a persons cancer. Knowing the stage of disease helps the doctor plan treatment and estimate the persons prognosis (see Question 1). Staging systems for cancer have evolved over time and continue to change as scientists learn more about cancer (see Question 2). The TNM staging system is based on the extent of the tumor (T), whether cancer cells have spread to nearby (regional) lymph nodes (N), and whether distant (to other parts of the body)metastasis (M) has occurred (see Question 3). Most tumors can be described as stage 0, stage I, stage II, stage III, or stage IV (see Question 3). Physical exams, imaging procedures, laboratory tests, pathology reports, and surgical reports provide information to determine the stage of the cancer (see Question 5). 1. What is staging? Staging describes the severity of a persons cancer based on the extent of the original (primary) tumor and whether or not cancer has spread in the body. Staging is important for several reasons: Staging helps the doctor plan the appropriate treatment. The stage can be used to estimate the persons prognosis. Knowing the stage is important in identifying clinical trials that may be suitable for a particular patient. Staging helps health care providers and researchers exchange information about patients; it also gives them a common terminology for evaluating the results of clinical trials and comparing the results of different trials. Staging is based on knowledge of the way cancer progresses. Cancer cells grow and divide without control or order, and they do not die when they should. As a result, they often form a mass of tissue called a tumor. As the tumor grows, it can invade nearby tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream or the lymphatic system. By moving through the bloodstream or lymphatic

system, cancer cells can spread from the primary site to lymph nodes or to other organs, where they may form new tumors. The spread of cancer is called metastasis. 2. What are the common elements of staging systems? Staging systems for cancer have evolved over time. They continue to change as scientists learn more about cancer. Some staging systems cover many types of cancer; others focus on a particular type. The common elements considered in most staging systems are as follows:

Site of the primary tumor. Tumor size and number of tumors. Lymph node involvement (spread of cancer into lymph nodes). Cell type and tumor grade* (how closely the cancer cells resemble normal tissue The presence or absence of metastasis.

cells).

3. What is the TNM system? The TNM system is one of the most widely used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). Most medical facilities use the TNM system as their main method for cancer reporting. PDQ, NCIs comprehensive cancer information database, also uses the TNM system. The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes(N), and the presence of distant metastasis (M). A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread. Primary Tumor (T) TX Primary tumor cannot be evaluated T0 No evidence of primary tumor Tis Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called preinvasive cancer) T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N) NX Regional lymph nodes cannot be evaluated N0 No regional lymph node involvement N1, N2, N3 Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)

Distant Metastasis (M) MX Distant metastasis cannot be evaluated M0 No distant metastasis M1 Distant metastasis is present

For example, breast cancer classified as T3 N2 M0 refers to a large tumor that has spread outside the breast to nearby lymph nodes but not to other parts of the body. Prostate cancer T2 N0 M0 means that the tumor is located only in the prostate and has not spread to the lymph nodes or any other part of the body. For many cancers, TNM combinations correspond to one of five stages. Criteria for stages differ for different types of cancer. For example, bladder cancer T3 N0 M0 is stage III, whereas colon cancer T3 N0 M0 is stage II. Stage Stage 0 Definition Carcinoma in situ.

Stage I, Higher numbers indicate more extensive disease: Larger tumor size and/or Stage II, and spread of the cancer beyond the organ in which it first developed to nearby Stage III lymph nodes and/or organs adjacent to the location of the primary tumor. Stage IV The cancer has spread to another organ(s).

Question 6 describes sources of additional information about staging for specific types of cancer. 4. Are all cancers staged with TNM classifications? Most types of cancer have TNM designations, but some do not. For example, cancers of the brain and spinal cord are staged according to their cell type and grade. Different staging systems are also used for many cancers of the blood or bone marrow, such as lymphomas. The Ann Arborstaging classification is commonly used to stage lymphomas and has been adopted by both the AJCC and the UICC. However, other cancers of the blood or bone marrow, including most types of leukemia, do not have a clear-cut staging system. Another staging system, developed by theInternational Federation of Gynecology and Obstetrics, is used to stage cancers of the cervix, uterus, ovary, vagina, and vulva. This system uses the TNM format. Additionally, childhood cancers are staged using either the TNM system or the staging criteria of the Childrens Oncology Group, which conducts pediatric clinical trials. Many cancer registries, such as NCIs Surveillance, Epidemiology, and End Results Program (SEER), use summary staging. This system is used for all types of cancer. It groups cancer cases into five main categories: In situ: Abnormal cells are present only in the layer of cells in which they developed. Localized: Cancer is limited to the organ in which it began, without evidence of spread. Regional: Cancer has spread beyond the primary site to nearby lymph nodes or organs and tissues. Distant: Cancer has spread from the primary site to distant organs or distant lymph nodes. Unknown: There is not enough information to determine the stage. 5. What types of tests are used to determine stage? The types of tests used for staging depend on the type of cancer. Tests include the following:

Physical exams are used to gather information about the cancer. The doctor examines the body by looking, feeling, and listening for anything unusual. The physical exam may show the location and size of the tumor(s) and the spread of the cancer to the lymph nodes and/or to other organs.

Imaging studies produce pictures of areas inside the body. These studies are important tools in determining stage. Procedures such as x-rays, computed tomography (CT) scans,magnetic resonance imaging (MRI) scans, and positron emission tomography (PET) scans can show the location of the cancer, the size of the tumor, and whether the cancer has spread.

Laboratory tests are studies of blood, urine, other fluids, and tissues taken from the body. For example, tests for liver function and tumor markers (substances sometimes found in increased amounts if cancer is present) can provide information about the cancer.

Pathology reports may include information about the size of the tumor, the growth of the tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor. Abiopsy may be performed to provide information for the pathology report. Cytology reports also describe findings from the examination of cells in body fluids.

Surgical reports tell what is found during surgery. These reports describe the size and appearance of the tumor and often include observations about lymph nodes and nearby organs. What causes cancer?

Anything that may cause a normal body cell to develop abnormally potentially can cause cancer. Many things can cause cell abnormalities and have been linked to cancer development. Some cancer causes remain unknown while other cancers may develop from more than one known cause. Some may be developmentally influenced by a person's genetic makeup. Many patients develop cancer due to a combination of these factors. Although it is often difficult or impossible to determine the initiating event(s) that cause a cancer to develop in a specific person, research has provided clinicians with a number of likely causes that alone or in concert with other causes, are the likely candidates for initiating cancer. The following is a listing of major causes and is not all-inclusive as specific causes are routinely added as research advances: Chemical or toxic compound exposures: Benzene, asbestos, nickel, cadmium, vinyl chloride, benzidine, N-nitrosamines, tobacco or cigarette smoke (contains at least 66 known potential carcinogenic chemicals and toxins), and aflatoxin Ionizing radiation: Uranium, radon, ultraviolet rays from sunlight, radiation from alpha, beta, gamma, and X-ray-emitting sources Pathogens: Human papillomavirus (HPV), EBV or Epstein-Barr virus,hepatitis viruses B and C, Kaposi's sarcoma-associated herpesvirus (KSHV), Merkel cell polyomavirus, Schistosoma spp., and Helicobacter pylori; other bacteria are being researched as possible agents Genetics: A number of specific cancers have been linked to human genes and are as follows: breast, ovarian, colorectal, prostate, skin and melanoma; the specific genes and other details are beyond the scope of this general article so the reader is referred tohttp://www.cancer.gov/cancertopics/genetics for more details about genetics and cancer. It is important to point out that most everyone is exposed to cancer-causing substances (for example, sunlight, cigarette smoke, and X-rays) during their lifetime but many individuals do not develop cancer. In addition, many people have the genes that are linked to cancer but do not develop it. Why? Although researchers may not be able give a satisfactory answer for every individual, it is clear that the higher the amount or level of cancer-causing materials a person is exposed to, the higher the chance the person will develop cancer. In addition, the people with genetic links to cancer may not develop it for similar reasons (lack of enough stimulus to make the genes function). In addition, some people may have a heightened immune response that

controls or eliminates cells that are or potentially may become cancer cells. There is evidence that even certain dietary lifestyles may play a significant role in conjunction with the immune system to allow or prevent cancer cell survival. For these reasons, it is difficult to assign a specific cause of cancer to many individuals. Proving that a substance does not cause or is not related to increased cancer risk is difficult. For example, antiperspirants are considered to possibly be related to breast cancer by some investigators and not by others. The official stance by the NCI is "additional research is needed to investigate this relationship and other factors that may be involved." This unsatisfying conclusion is presented because the data collected so far is contradictive. Other claims that are similar require intense and expensive research which may never be done. Reasonable advice might be to avoid large amounts of any compounds even remotely linked to cancer, although it may be difficult to do in complex, technologically advanced modern societies. What are cancer symptoms and signs? Symptoms and signs of cancer depend on the type of cancer, where it is located, and/or where the cancer cells have spread. For example, breast cancer may present as alump in the breast or as nipple dischargewhile metastatic breast cancer may present with symptoms of pain (if spread to bones), extreme fatigue (lungs), or seizures (brain). A few patients show no signs or symptoms until the cancer is far advanced. However, there are some signs and symptoms, although not specific, which usually occur in most cancer patients that are fairly easy for the person to detect. They are as follows: Fever (no clear infectious source, recurrent or constant) Fatigue (not relived by rest) Weight loss (without trying to lose weight) Pain (usually persistent) Skin changes (coloration, sores that do not heal, white spots in mouth or on tongue, wart changes)

Change in bowel or bladder functions (including trouble swallowing orconstipation) Unusual bleeding (mouth, vaginal, and bladder) or discharge Persistent cough or change in voice Lumps or tissue masses

Anyone with these signs and symptoms should consult their doctor. Many cancers will present with some of the above general symptoms but often have one or more symptoms that are more specific for the cancer type. For example, lung cancer may present with common symptoms of pain, but usually the pain is located in the chest. The patient may have unusual bleeding, but the bleeding usually occurs when the patient coughs. Lung cancer patients often become short of breath, and then become very fatigued. Because there are so many cancer types (see next section) with so many nonspecific and sometimes more specific symptoms, the best way to learn about signs and symptoms of specific cancer types is to spend a few moments researching symptoms of a specific body area in question. Conversely, a specific body area can be searched to discover what signs and symptoms a person should look for in that area that is suspected of having cancer. The following examples are two ways to proceed to get information on symptoms: Use a search engine (Google, Bing) to find links to cancer by listing the symptom followed by the term "cancer." For example, listing "blood in urine and cancer" will bring a person to web sites that list possible organs and body systems where cancer may produce the listed symptoms. Use a search engine as above and list the suspected body area and cancer (for example, bladder and cancer), and the person will see sites that list the signs and symptoms of cancer in that area (blood in urine being one of several symptoms listed).

In addition, if the cancer type is known (diagnosed), then even more specific searches can be done listing the diagnosed cancer type and whatever may be questioned about the cancer (symptoms, tumor grades, treatments, prognosis, and many other items). What are the different types of cancer? There are over 200 types of cancer; far too numerous to include in this introductory article. However, the NCI lists several general categories (see list in first section of this article). This list is expanded below to list more specific types of cancers found in each general category; it is not all inclusive and the cancers listed in quotes are the general names of some cancers: Carcinoma: Cancer that begins in the skin or in tissues that line or cover internal organs -- "skin, lung, colon, pancreatic, ovarian cancers," epithelial, squamous and basal cell carcinomas, melanomas, papillomas, and adenomas. Sarcoma: Cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue -- "bone, soft tissue cancers," osteosarcoma, synovialsarcoma, liposarcoma, angiosarcoma, rhabdosarcoma, and fibrosarcoma. Leukemia: Cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood -"leukemia," lymphoblastic leukemias (ALL and CLL), myelogenous leukemias (AML and CML), T-cell leukemia, and hairy-cell leukemia Lymphoma and myeloma: Cancers that begin in the cells of the immune system -"lymphoma," T-cell lymphomas, B-cell lymphomas,Hodgkin lymphomas, non-Hodgkin lymphoma, and lymphoproliferative lymphomas Central nervous system cancers: Cancers that begin in the tissues of the brain and spinal cord -- "brain and spinal cord tumors," gliomas, meningiomas, pituitary adenomas, vestibular schwannomas, primary CNS lymphomas, and primitive neuroectodermal tumors

Not included in the above types listed are metastatic cancers; this is because metastatic cancer cells usually arise from a cell type listed above and the major difference from the above types is that these cells are now present in a tissue from which the cancer cells did not originally develop. Consequently, if the terms "metastatic cancer" is used, for accuracy, the tissue from which the cancer cells arose should be included. For example, a patient may say they have or are diagnosed with "metastatic cancer" but the more accurate statement is "metastatic (breast, lung, colon, or other type) cancer." How is cancer diagnosed? A physical exam and medical history, especially the history of symptoms, are the first steps in diagnosing cancer. In many instances, the medical caregiver will order a number of tests, most of which will be determined by the type of cancer and where it is suspected to be located in or on the person's body. In addition, most caregivers will order a complete blood count, electrolyte levels and, in some cases, other blood studies that may give additional information (for example, a PSA or prostate specific antigen test may guide the caregiver to do additional tests, such as a prostate biopsy). Imaging studies are commonly used to help physicians detect abnormalities in the body that may be cancer. X-rays, CT and MRIscans, and ultrasound are common tools used to examine the body. Other tests such as endoscopy, which with variations in the equipment used, can allow visualization of tissues in the intestinal tract, throat, and bronchi that may be cancerous. In areas that cannot be well visualized (inside bones or some lymph nodes, for example), radionuclide scanning is often used. The test involves ingestion or IV injection of a weakly radioactive substance that can be concentrated and detected in abnormal tissue. The preceding tests can be very good at localizing abnormalities in the body; many clinicians consider that some of the tests provide presumptive evidence for the diagnosis of cancer. However, in most patients, the definitive diagnosis of cancer is based on the examination of a tissue sample from the tissue that may be cancerous by a qualified pathologist. Some biopsy samples are relatively simple to procure (for example, skin biopsy or intestinal tissue biopsy done with an endoscope equipped with a biopsy attachment). Other biopsies may require surgery

(for example, brain tissue or lymph node biopsy). In some instances, the surgery to diagnose the cancer may result in a cure if all of the cancerous tissue is removed at the time of biopsy. The biopsy can provide more than the definitive diagnosis of cancer; it can identify the cancer type (for example, a primary or metastatic type of brain cancer) and the "stage" of the cancerous cells. The stage or cancer staging is a way for clinicians and researchers to estimate how advanced or how severe the disease is. The following section describes the general staging methods for cancers. What is the treatment for cancer? The treatment for cancer is usually designed by a team of doctors or by the patient's oncologist and is based on the type of cancer and the stage of the cancer. Most treatments are designed specifically for each individual. In some people, diagnosis and treatment may occur at the same time if the cancer is entirely surgically removed when the surgeon removes the tissue for biopsy. Although patients may obtain a unique treatment protocol for their cancer, most treatments have one or more of the following components: surgery, chemotherapy,radiation therapy, or combination treatments (a combination of two or all three treatments). Individuals obtain variations of these treatments for cancer. Patients with cancers that cannot be cured (completely removed) by surgery usually will get combination therapy, the composition determined by the cancer type and stage. Palliative therapy (medical care or treatment used to reduce disease symptoms but unable to cure the patient) utilizes the same treatments described above. It is done with the intent to extend and improve the quality of life of the terminally ill cancer patient. There are many other palliative treatments to reduce symptoms such as pain medications and antinausea medications. What is the prognosis for cancer? The prognosis (outcome) for cancer patients may range from excellent to poor. The prognosis is directly related to both the type and stage of the cancer. For example, many skin cancers can be completely cured by removing the skin cancer tissue; similarly, even a patient with a large tumor may be cured after surgery and other treatments like chemotherapy (note that a cure is often defined by many clinicians as a five-year period with no reoccurrence of the cancer). However, as the cancer type either is or becomes aggressive, with spread to lymph nodes or is metastatic to other organs, the prognosis decreases. For example, cancers that have higher numbers in their staging (for example, stage III or T3N2M1; see staging section above) have a worse prognosis than those with low (or 0) numbers. As the staging numbers increase, the prognosis worsens. There are many complications that may occur with cancer; many are specific to the cancer type and stage and are too numerous to list here. However, some general complications that may occur with both cancer and its treatment protocols are listed below:

Fatigue (both cancer and treatments) Anemia (both) Loss of appetite (both) Insomnia (both) Hair loss (treatments mainly) Nausea (both) Lymphedema (both) Pain (both) Immune system depression (both)

Can cancer be prevented? Most clinicians and researchers are convinced that many cancers can either be prevented or the risk of developing cancers can be markedly reduced. Some of the methods are simple; others are relatively extreme, depending on an individual's view.

Prevention of cancer, by avoiding its potential causes, is the simplest method. First on most clinicians and researchers list is to stop (or better, never start) smokingtobacco. Avoiding excess sunlight (by decreasing exposure or applying sunscreen) and many of the chemicals and toxins is an excellent way to avoid cancers. Avoiding contact with certain viruses and other pathogens also is likely to prevent some cancers. People who have to work close to cancercausing agents (chemical workers, X-ray technicians, ionizing radiation researchers) should follow all safety precautions and minimize any exposure to such compounds. There are two vaccines currently approved by the U.S. Food and Drug Administration (FDA) to prevent specific types of cancer. Vaccines against the hepatitis B virus, which is considered a cause of some liver cancers, and vaccines against human papillomavirus types 16 and 18, which, according to the NCI, are responsible for about 70% of cervical cancer. Some clinicians and researchers recommend that all people, especially young teens, be vaccinated against the human papillomavirus, but this approach is still controversial. People with a genetic predisposition to develop certain cancers and others with a history of cancers in their genetically linked relatives currently cannot change their genetic makeup. However, some individuals who have a high possibility of developing genetically linked cancer have taken actions to prevent cancer development. For example, some young women who have had many family members develop breast cancer have elected to have their breast tissue removed even if they have no symptoms or signs of cancer development to reduce or eliminate the possibility they will develop breast cancer. Some doctors consider this as an extreme measure to prevent cancer while others do not. Screening studies for cancer, while they do not prevent cancers, may detect them at an earlier stage when the cancer is more likely to be potentially cured with treatment. Such screening studies are breast exams, testicular exams, colon-rectal exams (colonoscopy), mammography, PSA levels,prostate exams, and others. People who have any suspicion that they may have cancer should discuss their concerns with their doctor as soon as possible. The earlier cancer is disproved or diagnosed and treated, the person will be better served.