CANCER
Cancer is a class of diseases in which a group of cells display uncontrolled growth, invasion that intrudes upon and destroys adjacent tissues, and sometimes metastasis, or spreading to other locations in the body via lymph or blood. These three malignant properties of cancers differentiate them from benign tumors, which do not invade or metastasize.
Researchers divide the causes of cancer into two groups: those with an environmental cause and those with a hereditary genetic cause. Cancer is primarily an environmental disease, though genetics influence the risk of some cancers. Common environmental factors leading to cancer include: tobacco, diet and obesity, infections, radiation, lack of physical activity, and environmental pollutants. These environmental factors cause or enhance abnormalities in the genetic material of cells. Cell reproduction is an extremely complex process that is normally tightly regulated by several classes of genes, including oncogenes and tumor suppressor genes. Hereditary or acquired abnormalities in these regulatory genes can lead to the development of cancer. A small percentage of cancers, approximately five to ten percent, are entirely hereditary.
The presence of cancer can be suspected on the basis of symptoms, or findings on radiology. Definitive diagnosis of cancer, however, requires the microscopic examination of a biopsy specimen. Most cancers can be treated. Possible treatments include chemotherapy, radiotherapy and surgery. The prognosis is influenced by the type of cancer and the extent of disease. While cancer can affect people of all ages, and a few types of cancer are more common in children, the overall risk of developing cancer increases with age. In 2007 cancer caused about 13% of all human deaths worldwide (7.9 million). Rates are rising as more people live to an old age and lifestyles change in the developing world.
Cancers are classified by the type of cell that the tumor resembles and is therefore presumed to be the origin of the tumor. These types include:
- Carcinoma: Cancer derived from epithelial cells. This group includes many of the most common cancers, including those of the breast, prostate, lung and colon.
- Sarcoma: Cancer derived from connective tissue, or mesenchymal cells.
- Lymphoma and leukemia: Cancer derived from hematopoietic (blood-forming) cells
- Germ cell tumor: Cancer derived from pluripotent cells. In adults these are most often found in the testicle and ovary, but are more common in babies and young children.
- Blastoma: Cancer derived from immature "precursor" or embryonic tissue. These are also commonest in children.
Cancers are usually named using -carcinoma, -sarcoma or -blastoma as a suffix, with the Latin or Greek word for the organ or tissue of origin as the root. For example, a cancer of the liver is called hepatocarcinoma; a cancer of fat cells is called a liposarcoma. For some common cancers, the English organ name is used. For example, the most common type of breast cancer is called ductal carcinoma of the breast. Here, the adjective ductal refers to the appearance of the cancer under the microscope, which suggests that it has originated in the milk ducts.
Benign tumors (which are not cancers) are named using -oma as a suffix with the organ name as the root. For example, a benign tumor of smooth muscle cells is called a leiomyoma (the common name of this frequently occurring benign tumor in the uterus is fibroid). Confusingly, some types of cancer also use the -oma suffix, examples including melanoma and seminoma.
Cancer pathogenesis is traceable back to DNA mutations that impact cell growth and metastasis. Substances that cause DNA mutations are known as mutagens, and mutagens that cause cancers are known as carcinogens. Particular substances have been linked to specific types of cancer. Tobacco smoking is associated with many forms of cancer, and causes 90% of lung cancer.
Many mutagens are also carcinogens, but some carcinogens are not mutagens. Alcohol is an example of a chemical carcinogen that is not a mutagen. In Western Europe 10% of cancers in males and 3% of cancers in females are attributed to alcohol.
Decades of research has demonstrated the link between tobacco use and cancer in the lung, larynx, head, neck, stomach, bladder, kidney, esophagus and pancreas. Tobacco smoke contains over fifty known carcinogens, including nitrosamines and polycyclic aromatic hydrocarbons. Tobacco is responsible for about one in three of all cancer deaths in the developed world, and about one in five worldwide. Lung cancer death rates in the United States have mirrored smoking patterns, with increases in smoking followed by dramatic increases in lung cancer death rates and, more recently, decreases in smoking followed by decreases in lung cancer death rates in men. However, the numbers of smokers worldwide is still rising, leading to what some organizations have described as the tobacco epidemic.
Cancer related to one's occupation is believed to represent between 2–20% of all cases. Every year, at least 200,000 people die worldwide from cancer related to their workplace. Currently, most cancer deaths caused by occupational risk factors occur in the developed world. It is estimated that approximately 20,000 cancer deaths and 40,000 new cases of cancer each year in the U.S. are attributable to occupation. Millions of workers run the risk of developing cancers such as lung cancer and mesothelioma from inhaling asbestos fibers and tobacco smoke, or leukemia from exposure to benzene at their workplaces.
Diet, physical inactivity, and obesity are related to approximately 30–35% of cancer cases. In the United States excess body weight is associated with the development of many types of cancer and is a factor in 14–20% of all cancer death. Physical inactivity is believed to contribute to cancer risk not only through its effect on body weight but also through negative effects on immune system and endocrine system.
Diets that are low in vegetables, fruits and whole grains, and high in processed or red meats are linked with a number of cancers. A high salt diet is linked to gastric cancer, aflatoxin B1, a frequent food contaminate, with liver cancer, and Betel nut chewing with oral cancer. This may partly explain differences in cancer incidence in different countries for example gastric cancer is more common in Japan with its high salt diet and colon cancer is more common in the United States. Immigrants develop the risk of their new country, often within one generation, suggesting a substantial link between diet and cancer.
Worldwide approximately 18% of cancers are related to infectious diseases. This proportion varies in different regions of the world from a high of 25% in Africa to less than 10% in the developed world. Viruses are usual infectious agents that cause cancer but bacteria and parasites may also have an effect.
A virus that can cause cancer is called an oncovirus. These include human papillomavirus (cervical carcinoma), Epstein-Barr virus (B-cell lymphoproliferative disease and nasopharyngeal carcinoma), Kaposi's sarcoma herpesvirus (Kaposi's Sarcoma and primary effusion lymphomas), hepatitis B and hepatitis C viruses (hepatocellular carcinoma), and Human T-cell leukemia virus-1 (T-cell leukemias). Bacterial infection may also increase the risk of cancer, as seen in Helicobacter pylori-induced gastric carcinoma. Parasitic infections strongly associated with cancer include Schistosoma haematobium (squamous cell carcinoma of the bladder) and the liver flukes, Opisthorchis viverrini and Clonorchis sinensis (cholangiocarcinoma).
Up to 10% of invasive cancers are related to radiation exposure, including both ionizing radiation and non-ionizing radiation. Additionally, the vast majority of non-invasive cancers are non-melanoma skin cancers caused by non-ionizing radiation from ultraviolet radiation.
Sources of ionizing radiation include medical imaging, and radon gas. Radiation can cause cancer in most parts of the body, in all animals, and at any age, although radiation-induced solid tumors usually take 10–15 years, and up to 40 years, to become clinically manifest, and radiation-induced leukemias typically require 2–10 years to appear. Some people, such as those with nevoid basal cell carcinoma syndrome or retinoblastoma, are more susceptible than average to developing cancer from radiation exposure. Children and adolescents are twice as likely to develop radiation-induced leukemia as adults; radiation exposure before birth has ten times the effect. Ionizing radiation is not a particularly strong mutagen. Residential exposure to radon gas, for example, has similar cancer risks as passive smoking. Low-dose exposures, such as living near a nuclear power plant, are generally believed to have no or very little effect on cancer development. Radiation is a more potent source of cancer when it is combined with other cancer-causing agents, such as radon gas exposure plus smoking tobacco.
Unlike chemical or physical triggers for cancer, ionizing radiation hits molecules within cells randomly. If it happens to strike a chromosome, it can break the chromosome, result in an abnormal number of chromosomes, inactivate one or more genes in the part of the chromosome that it hit, delete parts of the DNA sequence, cause chromosome translocations, or cause other types of chromosome abnormalities. Major damage normally results in the cell dying, but smaller damage may leave a stable, partly functional cell that may be capable of proliferating and developing into cancer, especially if tumor suppressor genes were damaged by the radiation. Three independent stages appear to be involved in the creation of cancer with ionizing radiation: morphological changes to the cell, acquiring cellular immortality (losing normal, life-limiting cell regulatory processes), and adaptations that favor formation of a tumor. Even if the radiation particle does not strike the DNA directly, it triggers responses from cells that indirectly increase the likelihood of mutations.
Most cancers are initially recognized either because signs or symptoms appear or through screening. Neither of these lead to a definitive diagnosis, which usually requires the opinion of a pathologist, a type of physician (medical doctor) who specializes in the diagnosis of cancer and other diseases. People with suspected cancer are investigated with medical tests. These commonly include blood tests, X-rays, CT scans and endoscopy.
Palliative care is a multidisciplinary approach to symptom management to include physical, emotional, spiritual, and psycho-social distress. Palliative care is often confused with hospice, and therefore only involved when patients approach end of life despite the fact national guidelines recommend early palliative care involvement in certain individuals with cancer to assist with complex symptoms (pain, shortness of breath, fatigue, nausea) and coping with their illness. In people who have metastatic disease when first diagnosed, oncologists should consider a palliative care consult immediately. Additionally, an oncologist should consider a palliative care consult in any patient they feel has a prognosis of less than 12 months even if continuing aggressive treatment.
Cancer has a reputation as a deadly disease. Taken as a whole, about half of patients receiving treatment for invasive cancer (excluding carcinoma in situ and non-melanoma skin cancers) die from cancer or its treatment. However, the survival rates vary dramatically by type of cancer, with the range running from basically all patients surviving to almost no patients surviving.
Patients who receive a long-term remission or permanent cure may have physical and emotional complications from the disease and its treatment. Surgery may have amputated body parts or removed internal organs, or the cancer may have damaged delicate structures, like the part of the ear that is responsible for the sense of balance; in some cases, this requires extensive physical rehabilitation or occupational therapy so that the patient can walk or engage in other activities of daily living. Chemo brain is a usually short-term cognitive impairment associated with some treatments. Cancer-related fatigue usually resolves shortly after the end of treatment, but may be lifelong. Cancer-related pain may require ongoing treatment. Younger patients may be unable to have children. Some patients may be anxious or psychologically traumatized as a result of their experience of the diagnosis or treatment.
Survivors generally need to have regular medical screenings to ensure that the cancer has not returned, to manage any ongoing cancer-related conditions, and to screen for new cancers. Cancer survivors, even when permanently cured of the first cancer, have approximately double the normal risk of developing another primary cancer. Some advocates have promoted "survivor care plans"—written documents detailing the diagnosis, all previous treatment, and all recommended cancer screening and other care requirements for the future—as a way of organizing the extensive medical information that survivors and their future healthcare providers need.
Progressive and disseminated malignant disease harms the cancer patient's quality of life, and some cancer treatments, including common forms of chemotherapy, have severe side effects. In the advanced stages of cancer, many patients need extensive care, affecting family members and friends. Palliative care aims to improve the patient's immediate quality of life, regardless of whether further treatment is undertaken. Hospice programs assist patients similarly, especially when a terminally ill patient has rejected further treatment aimed at curing the cancer. Both styles of service offer home health nursing and respite care.
Predicting either short-term or long-term survival is difficult and depends on many factors. The most important factors are the particular kind of cancer and the patient's age and overall health. Medically frail patients with many comorbidities have lower survival rates than otherwise healthy patients. A centenarian is unlikely to survive for five years even if the treatment is successful. Patients who report a higher quality of life tend to survive longer.[94] People with lower quality of life may be affected by major depressive disorder and other complications from cancer treatment and/or disease progression that both impairs their quality of life and reduces their quantity of life. Additionally, patients with worse prognoses may be depressed or report a lower quality of life directly because they correctly perceive that their condition is likely to be fatal.
In the developed world, one in three people will be diagnosed with invasive cancer during their lifetimes. If all people with cancer survived and cancer occurred randomly, the lifetime odds of developing a second primary cancer would be one in nine. However, cancer survivors have an increased risk of developing a second primary cancer, and the odds are about two in nine. About half of these second primaries can be attributed to the normal one-in-nine risk associated with random chance. The increased risk is believed to be primarily due to the same risk factors that produced the first cancer (such as the person's genetic profile, alcohol and tobacco use, obesity, and environmental exposures), and partly due to the treatment for the first cancer, which typically includes mutagenic chemotherapeutic drugs or radiation. Cancer survivors may also be more likely to comply with recommended screening, and thus may be more likely than average to detect cancers.
While many diseases (such as heart failure) may have a worse prognosis than most cases of cancer, it is the subject of widespread fear and taboos. Euphemisms, once "a long illness", and now informally as "the big C", provide distance and soothe superstitions. This deep belief that cancer is necessarily a difficult and usually deadly disease is reflected in the systems chosen by society to compile cancer statistics: the most common form of cancer—non-melanoma skin cancers, accounting for about one-third of all cancer cases worldwide, but very few deaths—are excluded from cancer statistics specifically because they are easily treated and almost always cured, often in a single, short, outpatient procedure.
Cancer is regarded as a disease that must be "fought" to end the "civil insurrection"; a War on Cancer has been declared. Military metaphors are particularly common in descriptions of cancer's human effects, and they emphasize both the parlous state of the affected individual's health and the need for the individual to take immediate, decisive actions himself, rather than to delay, to ignore, or to rely entirely on others caring for him. The military metaphors also help rationalize radical, destructive treatments.
In the 1970s, a relatively popular alternative cancer treatment was a specialized form of talk therapy, based on the idea that cancer was caused by a bad attitude. People with a "cancer personality"—depressed, repressed, self-loathing, and afraid to express their emotions—were believed to have manifested cancer through subconscious desire. Some psychotherapists said that treatment to change the patient's outlook on life would cure the cancer. Among other effects, this belief allows society to blame the victim for having caused the cancer (by "wanting" it) or having prevented its cure (by not becoming a sufficiently happy, fearless, and loving person). It also increases patients' anxiety, as they incorrectly believe that natural emotions of sadness, anger or fear shorten their lives. The idea was excoriated by the notoriously outspoken Susan Sontag, who published Illness as Metaphor while recovering from treatment for breast cancer in 1978.
Although the original idea is now generally regarded as nonsense, the idea partly persists in a reduced form with a widespread, but incorrect, belief that deliberately cultivating a habit of positive thinking will increase survival. This notion is particularly strong in breast cancer culture.