Bladder cancer, 188.9
Breast cancer, 174.9
Cervical cancer, 180.0
Colorectal cancer, 154.0
Endometrial cancer, 182.0
Lung cancer, 162.9
Ovarian cancer, 183.0
Prostate cancer, 185.
I. General comments/incidence/predisposing factors
A. Leading cause of cancer deaths among men and women in the U.S.
B. Accounts for 13.4% of all new cancers
C. More people die from lung cancer than from colon cancer, breast cancer, and prostate cancer combined.
D. An estimated 213,380 new cases were expected to be diagnosed in 2007, with 160,390 deaths expected.
E. Increased incidence with
1. Tobacco smoking
a. Women who smoke have a greater risk of developing small cell rather than squamous cell lung cancer.
b. Men who smoke have a similar risk for small and non–small cell types.
2. Secondhand smoke
3. Ionizing radiation
4. Occupational exposure (may be additive or synergistic to tobacco)
a. Asbestos
b. Chromium
c. Nickel
d. Hydrocarbons
e. Chloromethyl ether
G. The average age of people found to have lung cancer is 60—unusual in those younger than age 40
H. If found and treated early, before lymph node or other organ involvement, the 5-year survival rate is 42%.
II. Subjective findings
A. In all, 10% to 25% of patients are asymptomatic at the time of diagnosis.
B. Symptomatic lung cancer is generally advanced disease.
C. May have nonspecific complaints such as
1. Weight loss
2. Chest pain
3. Dyspnea
4. Loss of appetite
D. Symptoms confined to the lungs
1. Cough
2. Hemoptysis
3. Hoarseness
4. Wheezing
5. Dyspnea
6. Sputum production with or without fever
7. Chest pain
8. Recurring infections such as bronchitis and pneumonia
III. Physical examination findings
A. Central tumors may obstruct the following areas of the lungs:
1. Segmental (left has eight segments, right has ten segments)
2. Lobar (left has two lobes, right has three lobes)
3. Mainstem bronchi (also cause atelectasis and postobstructive pneumonitis)
B. Peripheral tumors may cause no abnormalities on physical examination.
C. Tumor invasion of pleural surface may cause pleural effusion.
D. Disease confined to the chest may include the following physical findings:
1. Stridor, hoarseness
2. Changes on physical examination related to atelectasis
3. Consolidation
4. Diaphragm paralysis or effusion
5. Superior vena caval obstruction
a. Cyanosis
b. Engorgement of neck veins
c. Lack of pulsations
d. Enlarged neck circumference
e. Pericardial disease
f. Tamponade
F. Horner’s syndrome may be present.
1. Horner’s syndrome is the result of neurologic damage to cervical nerve.
2. It presents as unilateral miotic pupil, ptosis, and facial anhidrosis (inadequate perspiration).
G. Pancoast’s syndrome may be present.
1. Associated with tumor in apex of the lung
2. Symptoms include neuropathic pain in the arm and atrophy of the muscles of the arm and hand caused by brachial plexus and sympathetic ganglia tumor.
H. Malignant pleural effusions associated with bronchogenic carcinoma
IV. Laboratory/diagnostic findings
A. The only definitive test is biopsy.
B. Chest x-ray presentation varies with cell type.
C. Comparison with old films is extremely valuable.
1. Central lesions tend to be
a. Squamous cell carcinoma
b. Small cell carcinoma
2. Peripheral lesions tend to be
a. Adenocarcinoma
b. Large cell carcinoma
c. Bronchoalveolar cell carcinoma
3. Cavitation tends to be
a. Squamous cell carcinoma
b. Large cell carcinoma
4. Early mediastinal-hilar involvement is usually indicative of small cell carcinoma.
D. Sputum cytology 80%+ in centrally located lesions, less than 20% in peripheral nodules
E. Bronchoscopy may be used to obtain tissue for histologic confirmation.
F. Percutaneous needle aspiration
G. Pleural fluid, about 40% to 50%+ in malignant pleural effusion
H. Mediastinal exploration (rare)
I. Open biopsy is used only occasionally to confirm diagnosis when less invasive diagnostics are negative, or the lesion is inaccessible for other diagnostic modalities.
V. Major treatments
A. Refer to oncology specialist.
B. Therapy dependent on
1. Cell type
2. Premorbid condition
3. Underlying lung function
C. Small cell carcinoma (SCC)
1. Almost always treated with chemotherapy
3. Other names for small cell lung cancer are oat cell cancer and small cell undifferentiated.
D. SCC staged most often as
1. Limited stage—one lung and in lymph nodes on the same side of the chest
a. Most treated with chemotherapy such as cisplatin or carboplatin combined with etoposide
b. Clinical trials using paclitaxel are in progress.
c. SCC commonly spreads to the brain.
d. Patients treated with chemotherapy with or without radiation usually experience remission, although only temporarily.
e. Survival rates for limited-stage SCC treated with chemotherapy and radiation are 60% at 1 year, 30% at 2 years, and 10% to 15% by 5 years.
2. Extensive stage—both lungs, with spread to lymph nodes on the other side or to distant organs
a. Very poor prognosis when left untreated
b. Carboplatin or cisplatin and etoposide are the chemotherapy drugs usually used.
c. Radiation therapy is sometimes used.
d. Survival is 20% to 30% at 1 year, 5% by two years, and 1% to 2% by 5 years.
E. Non–small cell carcinoma (NSCC) is the most common type of lung cancer; it occurs in about 80% of lung cancers and includes
1. Squamous cell adenocarcinoma
2. Bronchoalveolar cell
3. Large cell
4. Adenosquamous cell
F. NSCC staged with TNM system
1. TNM = tumor, nodes, metastases
2. Described in Roman numerals 0 through IV (0 through 4). The lower the number, the less the cancer has spread.
3. Stage 0—limited to lining of air passages
a. Usually treated surgically with segmentectomy or wedge resection
b. Usually does not require chemotherapy
c. Usually does not require radiation
4. Stage I—invaded lung tissue
a. Usually involves lobectomy
b. Patient may receive radiation therapy.
c. Five-year survival with surgery about 60%
5. Stage II—invasion of lung tissue expanded
a. Treatment usually the same as in stage I
b. Five-year survival rates about 35% for patients with surgery
6. Stage IIIA—Treatment depends on location of cancer in the lung and whether it has spread to lymph nodes.
b. Chemotherapy or radiation therapy may be provided.
c. Brachytherapy (selective placement of radioactive source in contact with or implanted into tumor tissues) may be recommended.
d. Five-year survival range is 10% to 20%, or better if without lymph node metastases.
7. Stage IIIB—Cancer has spread too widely to be completely removed surgically.
a. May require chemotherapy or radiation
b. Five-year survival rate is 10% to 20%.
8. Stage IV—Cancer has spread to distant organs.
a. Cure is not possible.
b. Therapy is palliative.
c. Chemotherapy may prolong life.
d. One-year survival is about 20% to 25%.
G. Localized disease commonly treated with
1. Cisplatin
2. Vinblastine
H. Advanced disease commonly treated with
1. Cisplatin
2. Vinorelbine
I. Surgical resection may involve solitary nodule in localized disease stage I to IIIA.
J. Radiation therapy considered for nonsurgical candidates
K. Stage IIIB or IV usually receives
1. Palliative radiation
2. Experimental chemotherapy protocols
L. Therapeutic thoracentesis (if symptomatic) used with malignant pleural effusions
M. Decision algorithms for lung cancer detection and treatment were published in 2001.
COLORECTAL CANCER
I. General comments/predisposing factors
A. Third most common cause of cancer (excluding skin cancer) in males and females in the U.S.
B. Ninety-five percent of colorectal cancers are adenocarcinomas.
C. Increased incidence in those
1. Older than age 50
2. With a personal history of
a. Colorectal cancer
b. Colorectal adenomas
c. Inflammatory bowel disease
d. Peutz-Jeghers syndrome
f. Ovarian cancer
g. Endometrial cancer
h. Prostate cancer
i. Hereditary nonpolyposis colon cancer (HNPCC)
j. High-fat or low-fiber diet
3. With a family history of
a. Colorectal cancer
b. Cancer family syndrome
c. Gardner’s syndrome
II. Subjective findings
A. Often asymptomatic until disease is advanced
B. Bowel-specific symptoms include
1. Change in bowel habits
2. Bloody rectal discharge
3. Abdominal discomfort
4. Straining during a bowel movement
C. Systemic symptoms are frequently insidious and may include
1. Fatigue
2. Weight loss
3. Anemia
4. Nausea
5. Loss of appetite
III. Physical examination findings
A. Often, external examination of the abdomen is unrevealing.
B. Abdominal examination may reveal
1. Abdominal tenderness
2. That discrete mass may be palpated, dependent on tumor location and size
C. Digital rectal examination, combined with stool guaiac testing, is the most important part of the physical examination.
IV. Laboratory/diagnostic findings
A. Screening tests, recommended to begin at age 50 by both the American Cancer Society and the National Comprehensive Cancer Network, include
1. Fecal occult blood testing (FOBT)
2. Digital rectal examination (DRE)
3. Flexible sigmoidoscopy
4. Colonoscopy
5. Double-contrast barium enema
B. If there is reason to suspect colon or rectal cancer on history and physical examination regardless of age, the following should be considered:
1. DRE
2. FOBT
3. Colonoscopy
4. Biopsy
5. CBC
D. CT may be ordered.
E. Chest x-ray also may be ordered.
V. Evaluation for metastasis may include
A. CT-guided needle biopsy
B. MRI
C. Positron emission tomography (PET)
D. Angiography
E. Consultation with an enterostomal therapist
F. Bone scan
VI. Major treatments in general include
A. Surgery (treatment of choice)
1. Prior to surgery, treatments include
a. Liver function tests
b. CEA level
c. Colonoscopy
d. Chest film
B. Chemotherapy
1. Palliative
2. Not proved curative
3. 5-Fluorouracil (5-FU) is drug of choice for metastatic colorectal cancer. Frequently, leucovorin and oxaliplatin are used with 5-FU to enhance its effectiveness.
4. Levamisole HCl (Ergamisol) is used to reduce the rate of tumor recurrence.
C. Radiation therapy
1. Not primary treatment
2. May be used in conjunction with surgical excision of stage B2 and C rectal tumors
3. Owing to extensive lymphatic drainage in the rectum, rectal tumors tend to metastasize to regional lymph nodes early.
4. Radiation therapy inhibits metastasis.
D. See algorithms for therapy for different stages of colorectal cancer on the American Cancer Society Web site at www.cancer.org, or on the National Comprehensive Cancer Network Web site at www.ncc.org.
BREAST CANCER
I. General comments/predisposing factors
A. Most common nonskin malignancy in females in the U.S.
B. Second only to lung cancer as cause of death in women
C. Increased incidence in
2. Personal history of
a. Breast cancer
b. Colon cancer
c. Endometrial cancer
d. Ovarian cancer
e. Nulliparity, low parity, or late first pregnancy
f. Older than age 30 at first live birth
g. Early menarche, younger than age 12
h. Menopause after age 50
i. Cellular atypia or lobular carcinoma in situ on breast biopsy
j. Dense breast tissue
k. Radiation to breast or chest at moderate or high doses
3. Family history of
a. Breast cancer
b. Cancer family syndrome
D. Genetic mutations associated with breast cancer include
1. BRCA1
2. BRCA2
II. Subjective findings
A. Palpable, usually painless, breast lump is detected by the patient in most palpable breast cancers.
B. Nipple discharge (particularly if bloody and unilateral)
C. Focal breast pain with inflammation of the skin over the breast area may be associated with cancer but may also be associated with other, benign breast conditions.
D. Less frequent symptoms include
1. Breast pain
2. Nipple discharge
3. Erosion
4. Retraction
5. Enlargement
6. Itching of the nipple
7. Redness
8. Generalized hardness
9. Enlargement of the breast
10. Shrinking of the breast
III. Physical examination findings
A. Early findings
1. Single mass
2. Nontender
3. Firm to hard mass with ill-defined margins
4. Mammographic abnormalities
5. No palpable mass
C. Suspicion increased when
1. Mass is hard or fixed to the overlying skin
2. Overlying skin is dimpled or retracted
3. Unilateral bloody nipple discharge from the breast with the mass
4. New onset of inverted nipple with or without evidence of mass
5. Axillary adenopathy present (inconclusive finding)
6. Breast enlargement, redness, edema, pain
IV. Laboratory/diagnostic findings
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A. Confirmation of breast cancer requires cytologic or histologic finding.
1. Fine needle aspiration (a negative finding is not conclusive to rule out cancer)
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