Category Archives: Cancer

Ovarian cancer

Ovarian Cancer Information

Ovarian cancer is one of the leading causes of women’s deaths. The peak incidence of ovarian cancer is in late 50′s, while malignant germ cell cancer (one type of ovarian cancer) occurs in early 30′s. When abnormal cells divides too fast a cellular mass or tumor is formed which doesn’t invade to surrounding and are within a cell, this is called benign tumors and if the tumor spread to surrounding tissue or organ it is called malignant or cancerous and the process in with this cells invade surrounding is called metastasis.

Types of Ovarian Cancer:
There are 3 main types of ovarian cancer; primary epithelial cancer, Germ cell tumors and Sex cord tumors. Primary epithelial cancers comprise of 80-90% of all ovarian cancer and are classified into six histological types, of which Serous and Endometrioids are more common.

  • Serous (fallopian tube) – 40%
  • Endometrioid (endometrium) -24%
  • Mucinous (cervix)
  • Clear cell (mesonephros)
  • Transitional cells
  • Undifferentiated carcinoma

Germ cell tumors include endodermal sinus malignancies, embryonal carcinoma (a rare ovarian cancer that appears in children), immature teratomas, and dysgerminoma.

Sex cord (stromal) tumors include granulosa cell tumors (that produce estrogen and may have feminizing effects), granulosa-theca cell tumors, and the rare arrhenoblastomas (that produce androgen and have virilizing effects).

Causes and Risk Factors of Ovarian Cancer:

It is still unknown the real cause of ovarian tumors. However studies suggest that several factors including, hormonal, environmental, and genetic variables may play a role in causing ovarian cancer. Some of the risk factors are discussed below:

Family history of ovarian cancer:
Woman has as high as a 50% risk of getting ovarian cancer if two or more first-degree relatives (mother, sister, and daughter) have history of ovarian cancer. However women have less risk for second-degree relatives (grandmother, aunt, cousin).

The risk of developing ovaries cancer increase with increase age. Its incidence is high in late 50′s. Over 50% of cancer occurs in women older than 60 years.

Menstrual history/pregnancy history:
The risk of developing ovaries cancer is high in early menarche (less than 12 yrs) and late menopause (greater than 50 yrs). Late first child birth(after 35 yrs) may also be associated with risk of developing cancer.

Personal history:
Women who have breast cancer or other cancer have high risk of ovarian cancer then women who had not any previous cancer.

Talcum powder:
Some have suggested that women who apply talcum powder to the genital area or sanitary napkins have higher risk of developing ovarian cancer.

High-fat diet:
High fat diet is also linked in causing cancer, especially obesity is involve in risk of causing cancer.

Hormone replacement therapy (HRT):
There are some evidence that women who receives HRT after menopause have slightly increase risk for cancer but only with high dose and long-term use.
Other Risk factors of ovarian cancer may be repeated radiography of pelvis, late menarche and artificial menopause.

Acquired genetic mutations:
Researcher have suggested that genetic mutations of DNA alter oncogenes (genes that promote cancer cell division) tumor suppressor genes(cancer preventing genes) and other genes may results in high risk for ovarian cancer. Acquired mutations of the HER2 oncogene or the p53 tumor suppressor gene may be associated with a higher risk of ovarian cancer.

Ovarian Cancer Symptoms and Signs
Despite the common beliefs that early stage ovaries cancer is with out symptoms most women with ovaries cancer have vague symptoms such as lower abdominal pain abdominal distention and epigastric discomfort. The important sign being, pressure of pelvic mass during physical examination. If the cancer has metastasis to surrounding or has advanced then other symptoms like anorexia, fatigue, nausea, weight loss may be seen. So signs and symptoms of ovarian cancer may include the following:

  • Abdominal or pelvic discomfort or pressure
  • Back or leg pain
  • Changes in bowel function or urinary frequency
  • Fatigue, nausea, vertigo
  • Gastrointestinal symptoms (gas, long-term stomach pain, indigestion)
  • Abnormal vaginal bleeding
  • Feeling of fullness after a light meal

With only the symptoms it is not possible to diagnose the disease. There are more clinical lab, radiology and cytology findings which helps to confirm the disease. It requires detailed patient history, clinical evaluation, surgical exploration and some histological studies. Any enlargement of the ovary in post menopausal women is regarded as malignant cancer until proved. Laboratory tumor marker studies, such as Ca-125, human chorionic gonadotropin and carcinoembryonic antigen may be helpful to differentiate between benign or malignant process, although the marker may be negative in half of early stages of ovarian cancer. Abdominal and pelvic Ultrasonography or CT may help to determine the size of tumor. It may still be difficult to determine the benign or malignant nature of cancer until laparotomy.

Surgical exploration with biopsy will confirm the diagnosis of the disease. Abdomen is opened and explored and the tissue from the site is taken out for pathology studies.

Treatment of Ovarian Cancer:
Accurate pathologic evaluations and thorough surgical staging are essential to the management of early stage disease. In girls or young women who have unilateral encapsulated tumors and wish to maintain their fertility, resection of the ovary involved with consideration of later removal of another ovary after child bearing is suggested

For the patient who doesn’t like to have more child, Total Abdominal Hysterectomy with Bilateral Salpingo Oophorectomy can be done. Patients with stage Ia grade 1 or grade 2 tumors have very good prognosis and may not require additional chemo therapy.
Chemotherapy is very effective in ovarian cancer as adjuvant therapy and in achieving clinical remission. The current regimen for advance epithelial ovarian cancer is a combination of taxane and carboplatin and for germ cell tumors is cicplatin, etoposide and bleomycin.

Ovarian Cancer Prevention and Screening

The most important is by avoiding the risk factors which we have discussed above. Bilateral salpingo-oophorectomy at the time of hysterectomy in women over age 50 and after child bearing function has completed in younger women is advocated by many in prevention of development of ovarian cancer. No effective screening test for ovarian cancer is applicable to general population though women with strong family background should be considered for genetic counseling.

Known protective factors for ovarian cancer includes, child bearing and use of oral Contraceptive pills. Even 6 months of pills use seems to decrease the relative risk for ovarian cancer and the effect remains protective for up to 10 years. For patient with genetic mutation predisposing them to increase risk, prophylactic oophorectomy may be performed with or without prophylactic mastectomy for breast as well.

Breast Cancer

Breast Cancer Information

Breast cancer is the most common cancer in women who do not smoke. It is malignant neoplasm of the breast. It is estimated that one woman in nine will develop breast cancer in her lifetime and will have 3.5% chance dying from it.

How is Breast Cancer Diagnosed?

About 90% of the cases of breast cancer are discovered by breast self examination by patient them self. Screening is the method of diagnosing cancer at early stages before it produces any signs or symptoms which reduce the mortality by 50%. Positive diagnosis can be made by obtaining tissue for microscopic examination. The American cancer society recommends that all women should perform breast self examination monthly. In addition women from 20-40 years ages should visit the clinician every 3 years and women above 40 years every years. The risk of developing breast cancer increases with age.

Breast Self Examination:

  • Observe for symmetry, lumps, dimpling, nipple discharge or failure of nipple erection.
  • Gently squeeze nipple and observe for secretion and nipple erection after each nipple is gently stimulated.
  • While leaning forward, observe breast as they are reflected in mirror to detect irregularities, retracted areas especially one side only.
  • Feel for nodes irregularities and tenderness both in breast and axillaries nodes.

Symptoms of Breast Cancer:

Most women present with painless increasing mass which may also be associated with nipple discharge, ulceration and in inflammatory cancer edema and Erythema may be seen. There may be some non-specific symptoms such as weight loss, fatigue, anorexia, back or bone pain. This usually indicated more advanced stage of breast cancer.

Advanced Breast Cancer:

When breast cancer has advanced edema, redness, nodularity, ulceration of skin, presence large primary tumors which are fixed to chest wall, enlargement, shrinkage or retraction of the breast, marked axillary lymph nodes supra clavicular lymph nodes enlargement, edema of same sided hand or distant metastasis may be seen. 1-2 movable non-tender less than 5mm nodules are not suggestive of metastasis but nodules greater than 7mm usually contains metastasis. Axillary lymph nodes that are fixed to skin or deep structure indicates advanced disease.

What other disease you should consider?
There are several other diseases which may also gives same symptoms and signs as breast cancer. So these diseases can be excluded by obtaining a tissue biopsy of the site. Some other diseases to consider are:

  • Mammary dysplasia (cystic disease of the breast)
  • Fibro adenomas
  • Intraductal papilloma
  • Lipoma
  • fat necrosis

Risk factors of Breast Cancer

Breast is the most common site of cancer in women and accounts for second cause of death in women, first being lung cancer. Some risk factors of breast cancer are followings:

  • The most important being dietary factors especially high fat content (eg. red meat which have high saturated fat and protein content)
  • Women with previous cancer of uterine
  • It is more common in whites than non whites
  • Early menarche (less than 12 years) and late natural menopause (greater than 50 years are at high risk.
  • Late menarche and artificial menopause are at lower risk.
  • Women who had cancer of one breast are high risk of developing the other.
  • There is some evidence that administration of estrogen to post menopausal women has slightly increase risk of cancer but with higher dose and long term use.
  • Late first child birth (after 35 yrs) may also increase risk of developing breast cancer.

Treatment of Breast Cancer:

The type of treatment whether surgical, chemotherapy or combination of both therapies is determined by the extent of disease, patient age and her decision.

Early Breast Cancer Treatment:
Surgery with wide local excision and breast conservation or mastectomy with or with out re-construction is done. Amount of breast tissue to be removed still remains controversial. At one time radical mastectomy was done routinely although still performed, modified radical mastectomy, simple mastectomy or lumpectomy. Lumpectomy only removes cancerous portion of breast and axillary nodes. Radio therapy is given to conserve the breast after wide local excision to reduce local recurrence.

Adjuvant Systemic Treatment:
Tamoxifen adjuvant therapy immediately following surgery is beneficial for estrogen-progesterone receptor positive disease and has reduced the relative risk of women dying from breast cancer by 25%. Most commonly therapy with cyclophosphamide and 5-Flurouracil plus methotrexate for 5 months reduces the absolute by 10% and relative risk of death by 20%.

Advanced Breast Cancer Treatment:
Patient with establish metastasis disease may require endocrine therapy, chemo therapy or radiotherapy. The treatment is not curative but may be of great palliate benefits and consistent often with many years of good quality life. Recently addition of anti HER2 antibodies to chemo therapy has produced a modest survival advantage.

Endocrine Therapy for Advance Breast Cancer:
Women who have high level of estrogen receptor and progesterone in their tumor have greater chances of responding to endocrine therapy. A range of hormonal manipulations are as follows:
For premenopausal patients

  • Suppression of ovarian function by means of oophorectomy, radiation-induced ovarian ablation
  • Anti-oestrogen, Tamoxifen
  • Progesterone

For post menopausal women

  • Tamoxifen
  • Progesterone
  • Aromatase inhibitors (anastrozole)

Chemotherapy for Breast Cancer:
Patient who are unlikely to respond to hormonal therapy or who fail to respond to endocrine therapy or who requires rapid response  are given chemo therapy. The most common regimen used is:

  • CMF (cyclophosphamides, Methotrexate, 5-fluorouracil)
  • MM (mitoxantrone and methotrexate)
  • Doxyrubicin and cyclophosphamide
  • Paclitaxel or docetaxel used as single agent or in combination with an antracycline where initial therapy has failed or is inappropriate.

Side effect of Chemotherapy

  • Nausea, vomiting
  • Hair loss
  • Fatigue
  • Mucositis (eg. oesophagitis, diarrhea)

Drugs Specific Side Effects:

  • Anthracyclines causes cardio toxicity
  • 5-fluorouracil causes skin dermatitis

Poor Prognostic Factors for Breast Cancer

  • Young age
  • Pre-menopausal women
  • Tumor size
  • Metastasis of tumor
  • Oestrogen and progesterone receptor negative
  • Positive nodes.

Should I see the doctor after my treatment?
After primary therapy, patients with breast cancer should be followed for life for at least two reasons:

  • To detect recurrences and to observe the positive breast for secondary carcinoma.
  • Local or distant metastasis occurs frequently with in the first 3 years. So during this period patient is examined every 6 months. Thereafter, every 6-12 months for 5 years, then after every 12 months.