Disease Process Over a period of 5 years or longer, the adenomatous polyps degenerate into malignant tumors, which are most often located in the rectum or lower colon. The tumor spreads by direct extension through the bowel wall and by intraluminal, hematogenous, and regional lymph node metastases. The liver and lungs are common sites of distant metastasis.

Symptoms Cancer of the bowel is largely asymptomatic during the early stages. The most common presenting sign is rectal bleeding on defecation. Changes in bowel patterns, excessive gas, bloating, and cramping may also occur. Pain is unlikely until advanced stages of the disease.

Potential Complications The chance of survival falls below 50% with regional node involvement, and more than half of these individuals have node involvement at the time of diagnosis. Bowel obstruction or perforation, paralytic ileus, hemorrhage, and liver failure occur with advancing disease.

Diagnostic Tests A history of risk factors, positive result on occult fecal blood test, or palpable lesion on rectal examination indicates a need for follow-up. Visualization of a lesion by colonoscopy or barium enema examination or an elevated carcinoembryonic antigen level indicates the need for tissue biopsy, which is the only definitive mode of diagnosis.

Treatments

Surgery
Excision of welldifferentiated rectal tumors; resection of the colon around the tumor with removal of the associated lymphatic drainage system; colostomy; laser or bypass surgery for inoperable obstructing tumors.

Drugs
Adjunct systemic chemotherapy of 5-fluorouracil (5-FU) and levamisole for colon tumors; 5-FU and metronidazole for rectal tumors.

General
Radiation plus chemotherapy when four or more positive nodes are found and for palliation; instruction in ostomy care, ostomy support groups; counseling for altered body image.

Disease Process Cervical cancer begins as a neoplastic change in the cervical epithelium and eventually involves the full thickness of the epithelium. An invasive tumor forms in a cauliflower shape, with a friable texture and a hard, nodular edge. The bladder, rectum, and lungs are common sites of invasion and metastasis.

Symptoms Cervical cancer has no characteristic or typical symptom. Bleeding, which begins as a blood-tinged discharge and progresses to spotting and frank bleeding, is the only significant sign. The bleeding is caused by ulceration of the epithelial surface; however, some tumors spread without ulceration and thus without bleeding. Other possible indicators include prolonged menstrual periods or an increase in number of periods, and bleeding immediately after intercourse.

Potential Complications The prognosis with carcinoma in situ and noninvasive tumors is excellent, with survival rates approaching 100%. The prognosis with advanced disease is dismal, and complications arise from spread to the bowel, bladder, and pelvis and metastasis to the lung.

Diagnostic Tests If a Papanicolaou (Pap) smear of the cervix reveals atypical cells, a definitive diagnosis is obtained by colposcopy or biopsy. Cervicography may aid in staging of the tumor.

Treatments

Surgery
Conization, cryotherapy, electrocautery, laser ablation to treat carcinoma in situ; hysterectomy to treat tumors with no parametrial invasion; pelvic exenteration to treat advanced disease.

Drugs
Chemotherapy in experimental treatment stage for advanced disease.

General
Radiation to treat invasive disease and recurrences and as a palliative measure; counseling for body image and changes in sexual functioning.

Disease Process Cancer occurs when certain cells proliferate without organization and with little or no differentiation. It has been theorized that certain stimuli, as yet to be definitively identified, initiate this proliferation by overpowering the normal mechanisms controlling growth. The result is uninhibited growth, uncontrolled function, and rapid motility, permitting spread of the cancerous cells to other parts of the body through invasion of adjacent tissue or migration via the blood or lymph system. The migration process is commonly called metastasis. The primary site of a malignancy (cancer cell growth) is the site of original growth; a secondary site is created when cells migrate to and colonize an additional body site.

Symptoms The American Cancer Society lists seven warning signs of cancer that require immediate attention from a physician: (1) a change in bowel or bladder habits; (2) a sore that does not heal; (3) unusual bleeding or discharge; (4) a thickening or lump in the breast or elsewhere; (5) indigestion or difficulty swallowing; (6) an obvious change in a wart or mole; and (7) a nagging cough or hoarseness.

Potential Complications The prognosis generally declines as the disease stage advances (with evidence of lymph node involvement or metastasis). If the condition goes untreated, the cancer cells continue to proliferate, and eventually death results. Cardiac tamponade, pleural effusion, and paraneoplastic syndromes, which are all complications that can occur with various malignancies, are oncologic emergencies.

Diagnostic Tests Cancer screening is an important tool in the early detection and diagnosis of cancer. The following chart summarizes the American Cancer Society’s screening recommendations for asymptomatic individuals of average risk.

Examination
Sex
Age
Frequency

Sigmoidoscopy
M/F
.49
3-5 years

Stool blood test
M/F
.49
Annually

Digital rectal examination
M/F
.39
Annually

Prostate examination and prostatespecific antigen test
M
.49
Annually

Pap smear and pelvic examination
F
Sexually active or by age 18
Annually

Endometrial tissue sample
F
Menopause or high-risk individual*
Menopause

Breast self-examination
F
.19
Monthly

Clinical breast examination
F
20-39 .39
Every 3 years Annually

Mammography
F
40-49 .49
1-2 years Annually

Health counseling and cancer check-up ;
M/F
20-40 .40
Every 3 years Annually
*History of infertility, obesity, failure to ovulate, abnormal uterine bleeding, or estrogen therapy.
;Counseling on use of tobacco, sun exposure, diet, risk factors, sexual practices, and environmental and occupational exposures.
If screening techniques and the clinical examination indicate the possibility of cancer, a definitive diagnosis is made through histopathologic examination of tissue obtained by aspiration cytologic techniques or by excisional, endoscopic, or bone marrow biopsy. If an unequivocal diagnosis is made, staging is done for prognostic information and to guide treatment decisions. A comprehensive system known as the TNM system was developed. It involves assessment of three basic components: the size of the primary tumor (T); whether regional lymph nodes (N) are involved; and whether distant metastases (M) are present.

Treatments

Surgery
Removal of primary tumor with or without lymph nodes and adjacent structures; palliative procedures to relieve symptoms.

Drugs
Chemotherapeutic agents, hormones to reduce size of tumor and induce remission; immunotherapy or biologic response modifiers to strengthen immune function.

General
Radiation therapy to reduce size of tumor and check metastasis; bone marrow transplant.

Disease Process Ductal carcinomas originate in the lactiferous ducts, where the cancer cells form a dense fibrotic core with radiating tentacles that invade surrounding breast tissue. The tumor mass is generally solid, nonmobile, irregularly shaped, poorly defined, and unilateral. Lobular carcinomas originate in the breast lobules and are bilateral. Nipple carcinomas originate in the nipple complex and often occur in conjunction with invasive ductal carcinomas. The lungs, bones, brain, and liver are common sites of breast cancer metastasis.

Symptoms The most common presenting sign is a lump in the breast. About 50% are found in the upper outer quadrant. Nipple discharge may be present. Pain, tenderness, changes in breast shape, dimpling, and nipple retraction rarely occur until the disease reaches an advanced stage.

Potential Complications The prognosis dims markedly as the number of involved lymph nodes increases. Pleural effusion, ascites, pathologic fracture, and spinal compression can occur with advanced disease.

Diagnostic Tests A mass detected by breast self-examination, physical examination, or mammogram needs further follow-up. Definitive diagnosis is made by incisional, excisional, or needle biopsy of the mass.

Treatments

Surgery
Treatment of choice is resection of the lump with removal of a varying amount of surrounding healthy tissue, ranging from a margin of breast tissue to the entire breast, axillary lymph nodes, mammary lymphatic chain, and pectoral muscles; breast reconstruction.

Drugs
Adjunct systemic multidrug chemotherapy used primarily for premenopausal node-positive women; adjunct hormone therapy used primarily for postmenopausal nodeor receptor-positive women.

General
Radiation used as adjunct after surgery and for palliation in advanced disease; counseling for altered body image; recovery support groups; instruction in breast self-examination.

Disease Process As the tumor grows, the surrounding brain tissue is compressed or infiltrated (or both), causing focal disturbances. The flow and absorption of cerebrospinal fluid are altered and/or obstructed, causing increased intracranial pressure. Blood vessels are compressed, altering or obstructing blood flow and resulting in tissue necrosis and seizures. If tumors arise in certain locations, brain tissue can shift, leading to herniation, infarction, and hemorrhage in the pons and midbrain.

Symptoms The signs and symptoms depend heavily on the tumor’s location, size, and rate of growth. Slow-growing tumors are often asymptomatic until they have grown quite large.

General
Headache, nausea, vomiting, impulsivity, diminished judgment, memory impairment, depression, seizures, drowsiness, lethargy, psychotic episodes, papilledema

Focal
Frontal lobe: hemiplegia, expressive aphasia, ataxia, visual field defects, focal seizures Parietal lobe: focal sensory seizures, impaired position sense and two-point discrimination, hemianopsia, apraxia, anosognosia, speech disturbances, denial of illness Temporal lobe: convulsions, aphasia/dysphasia, olfactory aura preceding seizures Occipital lobe: hemianopsia, flashing light aura preceding seizures Brainstem: hemiplegia, hemianesthesia

Potential Complications Herniation of the brain can occur when intracranial pressure is expanded beyond compensatory levels. Prompt intervention is required, or the individual will die. Benign tumors that cannot be excised because of their size or location (or both) are generally fatal.

Diagnostic Tests

Clinical evaluation
Any of above manifestations, particularly headaches and recent onset of seizure activity

Neurologic examination
Focal manifestations, impairment of mental status

Computed tomography, magnetic resonance imaging, positron emission tomography
To detect tumor, midline shifts, and changes in ventricle size

Eye examination
To test visual fields and acuity and detect papilledema

Audiometry
To test hearing

Treatments

Surgery
Tumor excision, shunting.

Drugs
Corticosteroids to reduce cerebral edema; anticonvulsants to control seizure activity; chemotherapeutic agents as adjunctive therapy or to treat recurrence.

General
Radiation for tumor or residual tumor; rehabilitation for neurologic sequelae.