BREAST CANCER

There is no single, specic cause of breast cancer; rather, a combination of hormonal, genetic, and possibly
environmental events may contribute to its development.

Etiology
Hormones produced by the ovaries have an important role in breast cancer. Two key ovarian hormones, estradiol and
progesterone, are altered in the cellular environment by a variety of factors, and these may affect growth factors for
breast cancer.

HORMONES
The role of hormones and their relationship to breast cancer remain controversial. Research suggests that a relationship
exists between estrogen exposure and the development of breast cancer. In laboratory studies, tumors grow much
faster when exposed to estrogen, and epidemiologic research suggests that women who have longer exposure to
estrogen have a higher risk for breast cancer. Early menarche, nulliparity, childbirth after 30 years of age, and late
menopause are known but minor risk factors. The assumption is that these factors are all associated with prolonged
exposure to estrogen because of menstruation. The theory is that each cycle (which has high levels of endogenous
estrogen) provides the cells of the breast another chance to mutate, increasing the chance for cancer to develop.
Estrogen itself does not cause breast cancer, but it is associated with its development.

GENETICS
Growing evidence indicates that genetic alterations are associated with the development of breast cancer. These genetic
alterations include changes or mutations in normal genes and the inuence of proteins that either promote or suppress
the development of breast cancer. Genetic alterations may be somatic (acquired) or germline (inherited). To date, two
gene mutations have been identied that may play a role in the development of breast cancer. A mutation in the BRCA-1
gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2gene identies
risk for breast cancer, but less so for ovarian cancer (Houshmand, Campbell, Briggs et al., 2000). These gene mutations
may also play a role in the development of colon, prostate, and pancreatic cancer, but this is far from clear at present. It
has been estimated that 1 of 600 women in the general population has either a BRCA-1 or BRCA-2 gene mutation. For
women who carry either mutation, the risk for developing breast cancer can range from 50% to 90% (Kauff, Satagopan,
Robson et al., 2002). At present, only 5% to 10% of all breast cancers are estimated to be associated with the BRCA-1 or
BRCA-2 gene mutations. It is thought, however, that breast cancer is genetic and that up to 80% of women diagnosed
with breast cancer before age 50 years have a genetic component to their disease (Boyd, 1996). This is believed to be
linked to either unidentied BRCA-1 or BRCA-2 carriers or less penetrating genes that have yet to be identied through
genetics research. A womans risk for either BRCA-1 or BRCA-2 should be interpreted with caution and with an
exhaustive look at all her other risk factors; this is usually carried out by a genetics counselor. Abnormalities in either of
the two genes can be identied by a blood test; however, women should be counseled about the risks and benets
before actually undergoing genetic testing. The risks and benets of a positive or negative result should be explored.
Treatment options for a positive result are long-term surveillance, bilateral prophylactic mastectomy, or
chemoprevention with tamoxifen, as discussed previously. A positive result can cause tremendous anxiety and fear, can
unleash potential discrimination in employment and insurability, and can cause a woman to search for answers that may
not be available. A negative result can produce survivor guilt in a person with a strong family history of cancer. For these
women, the risk for breast cancer is similar to that of the general population, and routine screening guidelines should be
followed. The decision to pursue genetic testing must be made carefully, and women should be asked what they will do
differently after they know the results. Furthermore, because testing is relatively new and health care providers have yet
to determine a true benet from a positive or negative result, genetic testing should be done under the auspices of
clinical research protocols to protect the patient (because these data are kept separate from the patients medical
record). Nurses play a role in educating patients and their family members about the implications of genetic testing.
Ethical issues related to genetic testing include possible employment discrimination, bias in insurability and possibly with
insurance rates, and family members concerns (eg, effect on siblings, children).

Risk Factors
Although there are no specic known causes of breast cancer, researchers have identied a cluster of risk factors (Chart
48-3). These factors are important in helping to develop prevention programs. However, nearly 60% of women
diagnosed with breast cancer have no identiable risk factors other than their hormonal environment (Vogel, 2000).
Thus, all women are considered at risk for developing breast cancer during their lifetime. Nonetheless, identifying risk
factors provides a means for identifying women who may benet from increased surveillance and early treatment. In
addition, further research into risk factors will help in developing strategies to prevent or modify breast cancer in the
future. A high-fat diet was once thought to increase the risk of breast cancer. Epidemiologic studies of American and
Japanese women showed that American women had a vefold higher rate of breast cancer. Japanese women who
moved to the United States were shown to have breast cancer rates similar to their Caucasian counterparts. Recent
cohort studies show only weak or inconclusive relationships between a high-fat diet and breast cancer (Brown et al.,
2001). Because fat intake is implicated in colon cancer and heart disease, however, women may benefit from lowering
their intake of fat. Oral contraceptives were once thought to increase the risk for breast cancer. Currently, no
association is thought to exist in women in the general population, but there are no data about the effect on women
considered to be at high risk. The role of smoking in breast cancer remains unclear. Most studies suggest that smoking
does not increase a womans risk for breast cancer. Some studies, however, suggest that smoking does increase the risk
for breast cancer and that the earlier a woman begins smoking, the higher her risk. Smoking does increase the risk for
lung cancer, which is the leading cause of death in women with cancer (breast cancer is second). Smoking cessation is
part of a healthy lifestyle, and nurses have a key role in providing women with information about smoking cessation
programs. Silicone breast implants can be associated with brous capsular contraction, and some women and medical
professionals have claimed an association with certain immune disorders. There is no evidence, however, that breast
implants are associated with an increased risk of breast cancer.

Protective Factors
Certain factors may be protective in relation to the development of breast cancer. Regular, vigorous exercise has been
shown to decrease risk, perhaps because it can delay menarche, suppress menstruation, and, like pregnancy, reduce the
number of ovulatory menstrual cycles. Also, exercise decreases body fat, where estrogens are stored and produced from
other steroid hormones. Thus, decreased body fat can decrease extended exposure to estrogen.
Breastfeeding is also thought to decrease risk because it prevents the return of menstruation, again decreasing
exposure to endogenous estrogen. Having had a full-term pregnancy before the age of 30 years is also thought to be
protective. Protective hormones are released after delivery of the fetus, with the purpose of reverting to normal the
proliferation of cells in the breast that occur with pregnancy.

Clinical Manifestations
Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant, where most breast tissue
is located. Generally, the lesions are nontender rather than painful, xed rather than mobile, and hard with irregular
borders rather than encapsulated and smooth. Complaints of diffuse breast pain and tenderness with menstruation are
usually associated with benign breast disease. Marked pain at presentation, however, may be associated with breast
cancer in the later stages. With the increased use of mammography, more women are seeking treatment at an earlier
stage of disease. These women may have no symptoms and no palpable lump, but abnormal lesions are detected on
mammography. Unfortunately, many women with advanced disease seek initial treatment only after ignoring
symptoms. For example, they may seek attention for dimpling or for a peau dorange (orange-peel) appearance of the
skin (a condition caused by swelling that results from obstructed lymphatic circulation in the dermal layer). Nipple
retraction and lesions xed to the chest wall may also be evident. Involvement of the skin is manifested by ulcerating
and fungating lesions. These classic signs and symptoms characterize breast cancer in the late stages. A high index of
suspicion should be maintained with any breast abnormality, and abnormalities should be promptly evaluated.

Breast Cancer Staging

Staging involves classifying the cancer by the extent of disease (see Fig. 48-5). Staging of any cancer is important because
it helps the health care team identify and recommend the best treatment available, offer a prognosis, and compare the
results of various treatment regimens. Several diagnostic tests and procedures are performed in the staging of the
disease. These may include chest x-rays, bone scans, and liver function tests. Clinical staging involves the physicians
estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination (palpable
nodes may indicate progression of the disease) and mammography. After the diagnostic workup and the denitive
surgical treatment, the breast cancer is staged according to the TNM system (Greene, Page, Fleming, et al., 2002), which
evaluates the size of the tumor, number of nodes involved, and evidence of distant metastasis. Pathologic staging based
on histology provides information for a more accurate prognosis. Table 48-2 lists typical treatment guidelines by stage at
diagnosis (see the following management section for details regarding these treatments).

UTERINE CANCER

Endometrial cancer
Endometrial cancer is a type of cancer that begins in the uterus. The uterus is the hollow, pear-shaped pelvic organ in
women where fetal development occurs.

Endometrial cancer begins in the layer of cells that form the lining (endometrium) of the uterus. Endometrial cancer is
sometimes called uterine cancer. Other types of cancer can form in the uterus, including uterine sarcoma, but they are
much less common than endometrial cancer.

Endometrial cancer is often detected at an early stage because it frequently produces abnormal vaginal bleeding, which
prompts women to see their doctors. If endometrial cancer is discovered early, removing the uterus surgically often
cures endometrial cancer.

Symptoms

Signs and symptoms of endometrial cancer may include:

Vaginal bleeding after menopause

Bleeding between periods
An abnormal, watery or blood-tinged discharge from your vagina
Pelvic pain

When to see a doctor

Make an appointment with your doctor if you experience any signs or symptoms that worry you, such as vaginal
bleeding or discharge not related to your periods, pelvic pain, or pain during intercourse.

Causes

Doctors don't know what causes endometrial cancer. What's known is that something occurs to create a genetic
mutation within cells in the endometrium the lining of the uterus.

The genetic mutation turns normal, healthy cells into abnormal cells. Healthy cells grow and multiply at a set rate,
eventually dying at a set time. Abnormal cells grow and multiply out of control, and they don't die at a set time. The
accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can separate from an initial
tumor to spread elsewhere in the body (metastasize).

Risk factors

Factors that increase the risk of endometrial cancer include:

 Changes in the balance of female hormones in the body. Your ovaries make two main female hormones
estrogen and progesterone. Fluctuations in the balance of these hormones cause changes in your endometrium.

A disease or condition that increases the amount of estrogen, but not the level of progesterone, in your body can
increase your risk of endometrial cancer. Examples include irregular ovulation patterns, such as those that can
occur in women with polycystic ovary syndrome, obesity and diabetes. Taking hormones after menopause that
contain estrogen but not progesterone increases the risk of endometrial cancer.

A rare type of ovarian tumor that secretes estrogen also can increase the risk of endometrial cancer.

More years of menstruation. Starting menstruation at an early age before age 12 or beginning menopause
later increases the risk of endometrial cancer. The more periods you've had, the more exposure your endometrium
has had to estrogen.
Never having been pregnant. Women who have never been pregnant have a higher risk of endometrial cancer
than do women who have had at least one pregnancy.
Older age. As you get older, your risk of endometrial cancer increases. Endometrial cancer occurs most often in
women who have undergone menopause.
Obesity. Being obese increases your risk of endometrial cancer. This may occur because excess body fat alters your
body's balance of hormones.
Hormone therapy for breast cancer. Women with breast cancer who take the hormone therapy drug tamoxifen
have an increased risk of developing endometrial cancer. If you're taking tamoxifen, discuss this risk with your
doctor. For most women, the benefits of tamoxifen outweigh the small risk of endometrial cancer.
An inherited colon cancer syndrome. Hereditary nonpolyposis colorectal cancer (HNPCC) is a syndrome that
increases the risk of colon cancer and other cancers, including endometrial cancer. HNPCC occurs because of a
gene mutation passed from parents to children. If a family member has been diagnosed with HNPCC, discuss your
risk of the genetic syndrome with your doctor. If you've been diagnosed with HNPCC, ask your doctor what cancer
screening tests you should undergo.

Prevention

To reduce your risk of endometrial cancer, you may wish to:

Talk to your doctor about the risks of hormone therapy after menopause. If you're considering hormone
replacement therapy to help control menopause symptoms, talk to your doctor about the risks and benefits. Unless
you've undergone a hysterectomy, replacing estrogen alone after menopause may increase your risk of
endometrial cancer. Taking a combination of estrogen and progestin can reduce this risk. Hormone therapy carries
other risks, such as a possible increase in the risk of breast cancer, so weigh the benefits and risks with your doctor.
Consider taking birth control pills. Using oral contraceptives for at least one year may reduce endometrial cancer
risk. The risk reduction is thought to last for several years after you stop taking oral contraceptives. Oral
contraceptives have side effects, though, so discuss the benefits and risks with your doctor.
Maintain a healthy weight. Obesity increases the risk of endometrial cancer, so work to achieve and maintain a
healthy weight. If you need to lose weight, increase your physical activity and reduce the number of calories you
eat each day.
Exercise most days of the week. Exercise may reduce your risk of endometrial cancer. Add physical activity into
your daily routine. Try to exercise 30 minutes most days of the week. If you can exercise more, that's even better.
Diagnosing endometrial cancer

Pelvic exam
Transvaginal ultrasound
Hysteroscopy
Tests and procedures used to diagnose endometrial cancer include:

Pelvic examination. During a pelvic exam, your doctor carefully inspects the outer portion of your genitals (vulva),
and then inserts two fingers of one hand into your vagina and simultaneously presses the other hand on your
abdomen to feel your uterus and ovaries. He or she also inserts a device called a speculum into your vagina. The
speculum opens your vagina so that your doctor can view your vagina and cervix for abnormalities.
Using sound waves to create a picture of your uterus. Your doctor may recommend a transvaginal ultrasound to
look at the thickness and texture of the endometrium and help rule out other conditions. In this procedure, a
wandlike device (transducer) is inserted into your vagina. The transducer uses sound waves to create a video image
of your uterus. This test helps your doctor look for abnormalities in your uterine lining.
Using a scope to examine your endometrium.During a hysteroscopy, your doctor inserts a thin, flexible, lighted
tube (hysteroscope) through your vagina and cervix into your uterus. A lens on the hysteroscope allows your
doctor to examine the inside of your uterus and the endometrium.
Removing a sample of tissue for testing. To get a sample of cells from inside your uterus, you'll likely undergo an
endometrial biopsy. This involves removing tissue from your uterine lining for laboratory analysis. Endometrial
biopsy may be done in your doctor's office and usually doesn't require anesthesia.
Performing surgery to remove tissue for testing. If enough tissue can't be obtained during a biopsy or if the biopsy
results are unclear, you'll likely need to undergo a procedure called dilation and curettage (D&C). During D&C,
tissue is scraped from the lining of your uterus and examined under a microscope for cancer cells.
If endometrial cancer is found, you'll likely be referred to a doctor who specializes in treating cancers involving the
female reproductive system (gynecologic oncologist).

Staging endometrial cancer

Once your cancer has been diagnosed, your doctor works to determine the extent (stage) of your cancer. Tests used to
determine your cancer's stage may include a chest X-ray, a computerized tomography (CT) scan, positron emission
tomography (PET) scan and blood tests. The final determination of your cancer's stage may not be made until after you
undergo surgery to treat your cancer.

Stages of endometrial cancer include:

Stage I cancer is found only in your uterus.

Stage II cancer is present in both the uterus and cervix.
Stage III cancer has spread beyond the uterus, but hasn't reached the rectum and bladder. The pelvic area lymph
nodes may be involved.
Stage IV cancer has spread past the pelvic region and can affect the bladder, rectum and more-distant parts of your
body.
Treatment

Your options for treating your endometrial cancer will depend on the characteristics of your cancer, such as the stage,
your general health and your preferences.

Surgery
Surgery to remove the uterus is recommended for most women with endometrial cancer. Most women with
endometrial cancer undergo a procedure to remove the uterus (hysterectomy), as well as to remove the fallopian tubes
and ovaries (salpingo-oophorectomy). A hysterectomy makes it impossible for you to have children in the future. Also,
once your ovaries are removed, you'll experience menopause, if you haven't already.

During surgery, your surgeon will also inspect the areas around your uterus to look for signs that cancer has spread. Your
surgeon may also remove lymph nodes for testing. This helps determine your cancer's stage.

Radiation

Radiation therapy uses powerful energy beams, such as X-rays and protons, to kill cancer cells. In some instances, your
doctor may recommend radiation to reduce your risk of a cancer recurrence after surgery. In certain situations, radiation
therapy may also be recommended before surgery, to shrink a tumor and make it easier to remove.

If you aren't healthy enough to undergo surgery, you may opt for radiation therapy only. In women with advanced
endometrial cancer, radiation therapy may help control cancer-related pain.

Radiation therapy can involve:

Radiation from a machine outside your body. During external beam radiation, you lie on a table while a machine
directs radiation to specific points on your body.
Radiation placed inside your body. Internal radiation (brachytherapy) involves placing a radiation-filled device,
such as small seeds, wires or a cylinder, inside your vagina for a short period of time.
Hormone therapy

Hormone therapy involves taking medications that affect hormone levels in the body. Hormone therapy may be an
option if you have advanced endometrial cancer that has spread beyond the uterus.

Options include:

Medications to increase the amount of progesterone in your body. Synthetic progestin, a form of the hormone
progesterone, may help stop endometrial cancer cells from growing.
Medications to reduce the amount of estrogen in your body. Hormone therapy drugs can help lower the levels of
estrogen in your body or make it difficult for your body to use the available estrogen. Endometrial cancer cells that
rely on estrogen to help them grow may die in response to these medications.
Chemotherapy

Chemotherapy uses chemicals to kill cancer cells. You may receive one chemotherapy drug, or two or more drugs can be
used in combination. You may receive chemotherapy drugs by pill (orally) or through your veins (intravenously).
Chemotherapy may be recommended for women with advanced or recurrent endometrial cancer that has spread
beyond the uterus. These drugs enter your bloodstream and then travel through your body, killing cancer cells.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious
illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support
that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as
surgery, chemotherapy or radiation therapy.
When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and
live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams
aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative
or other treatments you may be receiving.

PROSTATE CANCER

Prostate cancer is cancer that occurs in the prostate a small walnut-shaped gland in men that produces the seminal
fluid that nourishes and transports sperm.

Prostate cancer is one of the most common types of cancer in men. Usually prostate cancer grows slowly and is initially
confined to the prostate gland, where it may not cause serious harm. However, while some types of prostate cancer
grow slowly and may need minimal or even no treatment, other types are aggressive and can spread quickly.

Prostate cancer that's detected early when it's still confined to the prostate gland has a better chance of successful
treatment.

Symptoms

Prostate cancer may cause no signs or symptoms in its early stages.

Prostate cancer that's more advanced may cause signs and symptoms such as:

Trouble urinating
Decreased force in the stream of urine
Blood in semen
Discomfort in the pelvic area
Bone pain
Erectile dysfunction

When to see a doctor

Make an appointment with your doctor if you have any signs or symptoms that worry you.

Debate continues regarding the risks and benefits of prostate cancer screening, and medical organizations differ on their
recommendations. Discuss prostate cancer screening with your doctor. Together, you can decide what's best for you.

Causes

It's not clear what causes prostate cancer.

Doctors know that prostate cancer begins when some cells in your prostate become abnormal. Mutations in the
abnormal cells' DNA cause the cells to grow and divide more rapidly than normal cells do. The abnormal cells continue
living, when other cells would die. The accumulating abnormal cells form a tumor that can grow to invade nearby tissue.
Some abnormal cells can also break off and spread (metastasize) to other parts of the body.

Risk factors

Factors that can increase your risk of prostate cancer include:

Age. Your risk of prostate cancer increases as you age.

Race. For reasons not yet determined, black men carry a greater risk of prostate cancer than do men of other
races. In black men, prostate cancer is also more likely to be aggressive or advanced.
Family history. If men in your family have had prostate cancer, your risk may be increased. Also, if you have a
family history of genes that increase the risk of breast cancer (BRCA1 or BRCA2) or a very strong family history of
breast cancer, your risk of prostate cancer may be higher.
Obesity. Obese men diagnosed with prostate cancer may be more likely to have advanced disease that's more
difficult to treat.

Complications

Complications of prostate cancer and its treatments include:

Cancer that spreads (metastasizes). Prostate cancer can spread to nearby organs, such as your bladder, or travel
through your bloodstream or lymphatic system to your bones or other organs. Prostate cancer that spreads to the
bones can cause pain and broken bones. Once prostate cancer has spread to other areas of the body, it may still
respond to treatment and may be controlled, but it's unlikely to be cured.
Incontinence. Both prostate cancer and its treatment can cause urinary incontinence. Treatment for incontinence
depends on the type you have, how severe it is and the likelihood it will improve over time. Treatment options may
include medications, catheters and surgery.
Erectile dysfunction. Erectile dysfunction can result from prostate cancer or its treatment, including surgery,
radiation or hormone treatments. Medications, vacuum devices that assist in achieving erection and surgery are
available to treat erectile dysfunction.

Prevention

You can reduce your risk of prostate cancer if you:

Choose a healthy diet full of fruits and vegetables. Avoid high-fat foods and instead focus on choosing a variety of
fruits, vegetables and whole grains. Fruits and vegetables contain many vitamins and nutrients that can contribute
to your health.

Whether you can prevent prostate cancer through diet has yet to be conclusively proved. But eating a healthy diet
with a variety of fruits and vegetables can improve your overall health.

Choose healthy foods over supplements. No studies have shown that supplements play a role in reducing your risk
of prostate cancer. Instead, choose foods that are rich in vitamins and minerals so that you can maintain healthy
levels of vitamins in your body.
 Exercise most days of the week. Exercise improves your overall health, helps you maintain your weight and
improves your mood. There is some evidence that men who don't exercise have higher PSA levels, while men who
exercise may have a lower risk of prostate cancer.

Try to exercise most days of the week. If you're new to exercise, start slow and work your way up to more exercise
time each day.

Maintain a healthy weight. If your current weight is healthy, work to maintain it by exercising most days of the
week. If you need to lose weight, add more exercise and reduce the number of calories you eat each day. Ask your
doctor for help creating a plan for healthy weight loss.

Diagnosis

Screening for prostate cancer

Digital rectal exam

Whether to test healthy men with no symptoms for prostate cancer is controversial. Medical organizations don't agree
on the issue of screening and whether it delivers benefits.

Some medical organizations recommend men consider prostate cancer screening in their 50s, or sooner for men who
have risk factors for prostate cancer.

Discuss your particular situation and the benefits and risks of screening with your doctor. Together, you can decide
whether prostate cancer screening is right for you.

Prostate screening tests might include:

Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine
your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size
of the gland, you may need further tests.
Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein in your arm and analyzed for PSA, a
substance that's naturally produced by your prostate gland. It's normal for a small amount of PSA to be in your
bloodstream. However, if a higher than normal level is found, it may indicate prostate infection, inflammation,
enlargement or cancer.
PSA testing combined with DRE helps identify prostate cancers at their earliest stages. Hence, debate continues
surrounding prostate cancer screening.

Diagnosing prostate cancer

If a DRE or PSA test detects an abnormality, your doctor may recommend further tests to determine whether you have
prostate cancer, such as:

Ultrasound. If other tests raise concerns, your doctor may use transrectal ultrasound to further evaluate your
prostate. A small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound
waves to create a picture of your prostate gland.
Collecting a sample of prostate tissue. If initial test results suggest prostate cancer, your doctor may recommend a
procedure to collect a sample of cells from your prostate (prostate biopsy). Prostate biopsy is often done using a
thin needle that's inserted into the prostate to collect tissue. The tissue sample is analyzed in a lab to determine
whether cancer cells are present.
 MRI fusion. While still being developed worldwide, MRI fusion to assist in prostate biopsy and diagnosis is being
used more and more.

LUNG CANCER

Lung cancer is a type of cancer that begins in the lungs. Your lungs are two spongy organs in your chest that take in
oxygen when you inhale and release carbon dioxide when you exhale.
Lung cancer is the leading cause of cancer deaths in the United States, among both men and women. Lung cancer claims
more lives each year than do colon, prostate, ovarian and breast cancers combined.
People who smoke have the greatest risk of lung cancer. The risk of lung cancer increases with the length of time and
number of cigarettes you've smoked. If you quit smoking, even after smoking for many years, you can significantly
reduce your chances of developing lung cancer.
SYMPTOMS
Lung cancer typically doesn't cause signs and symptoms in its earliest stages. Signs and symptoms of lung cancer
typically occur only when the disease is advanced.
Signs and symptoms of lung cancer may include:

A new cough that doesn't go away

Changes in a chronic cough or "smoker's cough"
Coughing up blood, even a small amount
Shortness of breath
Chest pain
Wheezing
Hoarseness
Losing weight without trying
Bone pain
Headache

Smoking causes the majority of lung cancers both in smokers and in people exposed to secondhand smoke. But lung
cancer also occurs in people who never smoked and in those who never had prolonged exposure to secondhand smoke.
In these cases, there may be no clear cause of lung cancer.
How smoking causes lung cancer
Doctors believe smoking causes lung cancer by damaging the cells that line the lungs. When you inhale cigarette smoke,
which is full of cancer-causing substances (carcinogens), changes in the lung tissue begin almost immediately.
At first your body may be able to repair this damage. But with each repeated exposure, normal cells that line your lungs
are increasingly damaged. Over time, the damage causes cells to act abnormally and eventually cancer may develop.
Types of lung cancer
Doctors divide lung cancer into two major types based on the appearance of lung cancer cells under the microscope.
Your doctor makes treatment decisions based on which major type of lung cancer you have. The two general types of
lung cancer include:

Small cell lung cancer. Small cell lung cancer occurs almost exclusively in heavy smokers and is less common than
non-small cell lung cancer.
Non-small cell lung cancer. Non-small cell lung cancer is an umbrella term for several types of lung cancers that
behave in a similar way. Non-small cell lung cancers include squamous cell carcinoma, adenocarcinoma and large cell
carcinoma.
RISK FACTORS
A number of factors may increase your risk of lung cancer. Some risk factors can be controlled, for instance, by quitting
smoking. And other factors can't be controlled, such as your family history.
Risk factors for lung cancer include:

Smoking. Your risk of lung cancer increases with the number of cigarettes you smoke each day and the number of
years you have smoked. Quitting at any age can significantly lower your risk of developing lung cancer.
Exposure to secondhand smoke. Even if you don't smoke, your risk of lung cancer increases if you're exposed to
secondhand smoke.
Exposure to radon gas. Radon is produced by the natural breakdown of uranium in soil, rock and water that
eventually becomes part of the air you breathe. Unsafe levels of radon can accumulate in any building, including
homes.
Radon testing kits, which can be purchased at home improvement stores, can determine whether levels are safe. If
unsafe levels are discovered, remedies are available.

Exposure to asbestos and other carcinogens. Workplace exposure to asbestos and other substances known to cause
cancer such as arsenic, chromium and nickel also can increase your risk of developing lung cancer, especially if
you're a smoker.
Family history of lung cancer. People with a parent, sibling or child with lung cancer have an increased risk of the
disease.

COMPLICATIONS
Lung cancer can cause complications, such as:

Shortness of breath. People with lung cancer can experience shortness of breath if cancer grows to block the major
airways. Lung cancer can also cause fluid to accumulate around the lungs, making it harder for the affected lung to
expand fully when you inhale.
Coughing up blood. Lung cancer can cause bleeding in the airway, which can cause you to cough up blood
(hemoptysis). Sometimes bleeding can become severe. Treatments are available to control bleeding.
Pain. Advanced lung cancer that spreads to the lining of a lung or to another area of the body, such as a bone, can
cause pain.
Tell your doctor if you experience pain. Pain may initially be mild and intermittent, but can become constant.
Medications, radiation therapy and other treatments may help make you more comfortable.
Fluid in the chest (pleural effusion). Lung cancer can cause fluid to accumulate in the space that surrounds the
affected lung in the chest cavity (pleural space).
Fluid accumulating in the chest can cause shortness of breath. Treatments are available to drain the fluid from your
chest and reduce the risk that pleural effusion will occur again.
Cancer that spreads to other parts of the body (metastasis). Lung cancer often spreads (metastasizes) to other parts
of the body, such as the brain and the bones.
Cancer that spreads can cause pain, nausea, headaches, or other signs and symptoms depending on what organ is
affected. Once lung cancer has spread to other organs, it's generally not curable. Treatments are available to
decrease signs and symptoms and to help you live longer.

Leiomyosarcoma (LMS) is a type of soft tissue sarcoma. Soft tissue sarcomas can develop in muscle, fat, blood vessels,
or any of the other tissues that support, surround and protect the organs of the body.

Leiomyosarcoma is one of the more common types of soft tissue sarcoma to develop in adults. We dont yet know the
exact cause.
What are neutropenic precautions?

Neutropenic precautions are steps you can take to prevent infections if you have moderate to severe neutropenia.
Neutropenia is a condition that causes you to have low neutrophils in your blood. Neutrophils are a type of white blood
cell that help your body fight infection and bacteria. Ask your healthcare provider for more information on neutropenia.

What precautions can I take to prevent infections?

Stay away from crowds and people who are sick. This will decrease your risk of infections that can be passed to you from
others. The following are other ways to prevent infections:

Wash your hands often. Use soap and water. Wash your hands after you use the bathroom, change a child's
diaper, sneeze, or cough. Wash your hands before you prepare or eat food. Wash your hands after you visit
public places. Dry your hands completely.
Bathe daily. This lowers the amount of germs on your skin. Germs can cause infections. If you shave, use an
electric razor to prevent cuts in the skin where germs can get in.
Brush your teeth 2 times each day. Brush gently with a soft toothbrush. The mouth is a common place for
infections. Ask your healthcare provider if it is okay for you to gently floss daily.
Prevent constipation. Ask your healthcare provider if you should take a stool softener. Ask him how much liquid
to drink and which liquids are best for you. Do not use suppositories or enemas. Constipation, suppositories, and
enemas can cause a tear in your rectum. This allows germs to get in and can increase your risk for infection.
Do not use tampons or douches. These may cause tears in your vagina that germs can get into.
Do not share personal items with anyone. Some examples are drinking glasses, eating utensils, and bath towels.
Avoid fresh flowers, live plants, and standing water. They may have germs growing from the soil or water.
Have someone clean up after your pet. Contact with your pet's feces, urine, and saliva may give you an
infection. Ask someone to clean your birdcages, or fish or turtle tanks for you. Ask someone to clean your cat
box daily.

What precautions do I need to take with my food?

Eat foods that are high in calories, protein, and vitamins to help you heal. Eat only foods that are pasteurized. You can
get infections from food or drinks while your neutrophils are low. Follow these and any other precautions from your
healthcare provider:

Wash your hands, kitchen surfaces, and food. Germs can be on your hands, counter tops, utensils, and food.
Wash your hands before and after you handle food. Wash countertops and utensils with hot soapy water
between food items, especially raw meats, fish, and poultry. Wash fresh fruits and vegetables thoroughly before
you eat or cook them. Clean the tops of cans before you open them.
Keep cooked and raw foods separate in your grocery cart, grocery bags, and refrigerator. This prevents cross
contamination. Cross contamination is when germs from one food spread to another food. This happens when
juices from raw meat, fish, and eggs get on cooked or ready-to-eat foods. Use a separate cutting board for raw
foods. Never put cooked food on an unwashed plate that had raw meat, seafood, or eggs on it.
Cook your food all the way through. Germs are destroyed when you cook your food to safe temperatures. Use a
food thermometer to make sure your food is cooked to the correct temperature. You cannot always tell if your
food is safe by looking at it. Cover, stir, and rotate food that you cook in a microwave so that it cooks evenly.
Refrigerate food immediately. This will help slow down the growth of germs. Your refrigerator should be at 40F
or below to keep foods safe. Put meat, poultry, eggs, and seafood in the refrigerator or freezer within 2 hours
 after cooking or buying them. Always thaw food in the refrigerator, cold water, or microwave. Do not thaw food
on your countertop.

When should I seek immediate care?

You have a fever of 100.4F (38C) for more than 1 hour.

You have a fever of 101.0F (38.3C) or higher once.

When should I contact my healthcare provider?

You have fever or chills.

You have a new cough.
You have a sore throat or a new mouth sore.
You have redness or swelling any place on your body.
You have pain in your abdomen or rectum.
You have burning or pain when you urinate.
You have diarrhea.
You are more tired or forgetful than usual.
You are planning to travel.
You have questions or concerns about your condition or care.
Cancers that Develop in Children

The types of cancers that occur most often in children are different from those seen in adults. The most common cancers
of children are:

Leukemia

Brain and spinal cord tumors

Neuroblastoma

Wilms tumor

Lymphoma (including both Hodgkin and non-Hodgkin)

Rhabdomyosarcoma

Retinoblastoma

Bone cancer (including osteosarcoma and Ewing sarcoma)

Other types of cancers are rare in children, but they do happen sometimes. In very rare cases, children may even develop
cancers that are much more common in adults.

Leukemia

Leukemias, which are cancers of the bone marrow and blood, are the most common childhood cancers. They account for
about 30% of all cancers in children. The most common types in children are acute lymphocytic leukemia (ALL) and acute
myelogenous leukemia (AML). These leukemias can cause bone and joint pain, fatigue, weakness, pale skin, bleeding or
bruising, fever, weight loss, and other symptoms. Acute leukemias can grow quickly, so they need to be treated (typically
with chemotherapy) as soon as they are found.

Brain and spinal cord tumors

Brain and central nervous system tumors are the second most common cancers in children, making up about 26% of
childhood cancers. There are many types of brain tumors, and the treatment and outlook for each is different.

Most brain tumors in children start in the lower parts of the brain, such as the cerebellum or brain stem. They can cause
headaches, nausea, vomiting, blurred or double vision, dizziness, seizures, trouble walking or handling objects, and other
symptoms. Adults are more likely to develop tumors in upper parts of the brain. Spinal cord tumors are less common than
brain tumors in both children and adults.

Neuroblastoma

Neuroblastoma starts in early forms of nerve cells found in a developing embryo or fetus. About 6% of childhood cancers
are neuroblastomas. This type of cancer develops in infants and young children. It is rarely found in children older than
10. The tumor can start anywhere but usually starts in the belly (abdomen) where it is noticed as swelling. It can also
cause bone pain and fever.

Wilms tumor

Wilms tumor (also called nephroblastoma) starts in one, or rarely, both kidneys. It is most often found in children about 3
to 4 years old, and is uncommon in children older than age 6. It can show up as a swelling or lump in the belly (abdomen).
Sometimes the child might have other symptoms, like fever, pain, nausea, or poor appetite. Wilms tumor accounts for
about 5% of childhood cancers.

Lymphomas

Lymphomas start in immune system cells called lymphocytes. They most often start in lymph nodes and other lymph
tissues, like the tonsils or thymus. These cancers can also affect the bone marrow and other organs. Symptoms depend
on where the cancer is and can include weight loss, fever, sweats, tiredness (fatigue), and lumps (swollen lymph nodes)
under the skin in the neck, armpit, or groin.

The 2 main types of lymphoma are Hodgkin lymphoma (sometimes called Hodgkin disease) and non-Hodgkin lymphoma.
Both types occur in children and adults.

Hodgkin lymphoma accounts for about 3% of childhood cancers. It is more common, though, in early adulthood (age 15
to 40, usually people in their 20s) and late adulthood (after age 55). Hodgkin lymphoma is rare in children younger than 5
years of age. This type of cancer is very similar in children and adults, including which types of treatment work best.

Non-Hodgkin lymphoma makes up about 5% of childhood cancers. It is more likely to occur in younger children than
Hodgkin lymphoma, but it is still rare in children younger than 3. The most common types of non-Hodgkin lymphoma in
children are different from those in adults. These cancers often grow quickly and require intensive treatment, but they also
tend to respond better to treatment than most non-Hodgkin lymphomas in adults.

Rhabdomyosarcoma

Rhabdomyosarcoma starts in cells that normally develop into skeletal muscles. (These are the muscles that we control to
move parts of our body.) This type of cancer can start nearly any place in the body, including the head and neck, groin,
belly (abdomen), pelvis, or in an arm or leg. It may cause pain, swelling (a lump), or both. This is the most common type
of soft tissue sarcoma in children. It makes up about 3% of childhood cancers.

Retinoblastoma

Retinoblastoma is a cancer of the eye. It accounts for about 2% of childhood cancers. It usually occurs in children around
the age of 2, and is seldom found in children older than 6. Retinoblastomas are usually found because a parent or doctor
notices a childs eye looks unusual. Normally when you shine a light in a childs eye, the pupil (the dark spot in the center
of the eye) looks red because of the blood in vessels in the back of the eye. In an eye with retinoblastoma, the pupil often
looks white or pink. This white glare of the eye may be noticed after a flash picture is taken.

Bone cancers

Cancers that start in the bones (primary bone cancers) occur most often in older children and teens, but they can develop
at any age. They account for about 3% of childhood cancers.

Two main types of primary bone cancers occur in children:

Osteosarcoma is most common in teens, and usually develops in areas where the bone is growing quickly, such as near
the ends of the long bones in the legs or arms. It often causes bone pain that gets worse at night or with activity. It can
also cause swelling in the area around the bone.

Ewing sarcoma is a less common type of bone cancer, which can also cause bone pain and swelling. It is most often
found in young teens. The most common places for it to start are the pelvic (hip) bones, the chest wall (such as the ribs or
shoulder blades), or in the middle of the long leg bones.