Cancer (Malignancy)

December 14, 2007

What is Meant by "Female" Cancer?

When I take a medical history from a patient, "female" cancer is that vague label placed on the cause of death of so many grandmothers and great aunts. A few generations ago, women didn't talk about such things to their families.  After all, this was an illness that involved the reproductive tract, and modesty demanded that such subjects be strictly taboo.  This void of important information creates a frustration of sorts for the physician, because it's so helpful to know just what type of "female" cancer a relative had.  The dreaded term "female" cancer puts a big hole in the patient's family history, and what type of cancer runs in the family impacts on how I address certain symptoms.

Today we aren't embarrassed to hear such terms as uterine cancer, breast cancer, or ovarian cancer.

Frightened yes, but embarrassed no.

The female reproductive tract develops in a very complex way.  Many different types of tissue intermingle into a consortium to provide for reproduction, urinary functions, and sexual response.  At each level of a woman's pelvic and sex organs there are opportunities for tissues to go awry. The result is cancer.

The Ovary:

Ovarian cancer may develop from either ovarian tissue itself or from the lining that surrounds the ovary.  This lining, peritoneum, is the same stuff that lines the rest of the inside of the abdomen.  The peritoneum is very strange tissue indeed, and many scientists theorize that, almost like fetal tissue, it seems to have the ability to develop into other types of tissue.  Many feel that it can become abnormal in the ovary, distorting in several ways, mimicking other pelvic tissues.  Because of this, ovarian cancer can be like cancer of the cervix, cancer of the uterus, or cancer of the tubes.  The ovary, therefore, besides being able to develop its own tissue-related cancer, can actually harbor cancers made up of tissue found in other pelvic organs.  A test called CA-125 is the one that rises with these peritoneal-lining type cancers.  Called "epithelial" tumors, they're just as deadly as the purely ovarian types.

Ovarian cancer is often silent until found accidentally in the course of a routine GYN exam.  If fairly advanced, it can cause mysterious weight loss, bloating, and nausea.  But it's the initial silence that makes it so dangerous, often having spread in runaway fashion by the time symptoms develop.

See also, Ovarian Cysts--the Good, the Bad, and the Ugly

The fallopian tubes:

These are the structures that carry an egg down to the uterus (womb).  Cancer of the fallopian tubes, though, is very rare.  It presents usually with blood stained vaginal discharge, but so can a yeast infection.  At Charity Hospital (or whatever they're calling it nowadays), there was a saying: "When you hear hooves, assume horses, not zebras."  This meant that a doctor should assume the most likely diagnosis, and a bloody discharge that's fallopian tube cancer is certainly a zebra, with about as much of a chance of being the explanation of such a discharge as there is of a zebra actually running down Tulane Avenue in front of Charity.  I have yet to see a case.

The uterus:

Cancer of the uterus usually presents with vaginal bleeding after the menopause.  Ultrasound, endometrial biopsies (a little straw through the cervix to retrieve tissue), and d & c (dilatation and curettage, i.e., scraping the entire womb to study the tissue--the endometrial biopsy's big brother) are used to investigate this very serious patient complaint.  A Pap smear can't check for this, because this is tissue deeper into the body of the uterus, whereas a Pap smear is merely a scraping of the surface of the cervix (mouth of the womb) to study cervical cells. Any bleeding after the menopause is serious business till proven otherwise.  Often the bleeding is caused by us doctors while hormonally manipulating away hot flashes and menopausal moodiness and headaches.  But this bleeding still needs evaluation, regardless of the most likely cause being doctor-caused, because the zebra of uterine cancer is much more common than cancer of the tubes.  Uterine cancer begins with an abnormality of the normal endometrial tissue in the uterus piling up and distorting into something called endometrial hyperplasia (overgrowth).

(The old way of giving only estrogen as hormonal replacement used to cause the precancerous condition, endometrial hyperplasia, until we figured out that progesterone could prevent that if given with the estrogen.)

The cancers above all follow, along with the breast, a familial pre-disposition.  That is, if a woman has a family history of one of these types of cancer, then her doctor must be wary to ignore no symptoms, because she's at an increased risk because of the afflicted people she's related to.  This is in contrast to cervical cancer, which is not familial.

The cervix:

Cervical cancer is not more likely in relatives of those who have had this particular type of malignancy.  This is because it is thought to be caused by a virus, HPV, which is sexually acquired, especially in combination with cigarette smoking (no one ever talks about that!).  In contrast, there seems to be a breast-uterus-ovarian tendency that makes one prone to one of these types of cancer if she herself or one of her relatives has had one of the other two.

Because there are over a dozen types of "female" cancer, some more likely with a strong family history, it's become increasingly important to delve into the secrets of the past.  All women who have descended from victims of "female" cancer should ask as many questions as possible to try to nail down the distinctions that could make a difference.  True, this knowledge may be forever locked away in the graves of generations gone by, but it doesn't hurt for a woman to ask. Breast Cancer

"Because we're mammals, we have retained several physical characteristics that are pinnacles of evolution. None is more nurturing to our kind, however, as breast-feeding. The breast, or mammary gland, creates bonding, affection, and warmth of the maternal-newborn exchange that snuggling in this way affords. The infant's face, where most of the nerve sensitivity is centered, is surrounded by motherly bosom--a physical act of love from which love literally flows. The lactating breast answers the infant's mouth, satisfying a void that suckling fills. Indeed, the mother and breast-feeding child constitute a different mammal altogether, a unique unit of togetherness. That's the good news. The bad news is that now that we've extended our life expectancies well beyond the breast-feeding years, age-related malignancies are now commonplace."

The statistics for breast cancer are staggering, because one out of nine will develop it.  Even with improved screening techniques, rapidity of diagnosis, and better treatments, more and more women are dying of this disease.  In the last thirty years, the number of new breast cancers has doubled, and today almost 50,000 women die every year from it.

There are two reasons for this increasing number:

  • Diagnostics are getting better and achieving a diagnosis earlier.  In the past, a woman might die from a "female" cancer, which would blunt the statistics on actual breast cancer.
  • Women are living to be older, along with the men, so diseases that increase based on advancing age are rising in modern society more than ever.

A woman's best chances rely on discovering the disease as early as possible, allowing treatment when it is its most vulnerable. So, crucial to this advantage are the following:

  • Self-examination
  • Regular physician exams
  • Routine mammograms (or more than the routine if there's a family history of breast cancer)
  • Seeing a doctor for any discovered lumps or secretions of the breast.

Early Diagnosis

When it comes to breast disease, the quick will outlive the procrastinators.

Anytime a breast goes "Boo!" with a mass doesn't portend doom, thank goodness. Most masses are benign, treated with diet changes, caffeine and nicotine restriction, or at worst removal to prove the benign nature. But a woman and her doctor must spin the wheels to seperate the harmless from the harmful lumps.

One normal variation, Fibrocystic Breast Disease, can continually worry a woman with lumpy breasts.  But "Disease" is a bad word for this condition, because it is really a normal variation, and it is particulary sensitive, as mentioned above, to diet, coffee, tea, smoking, and other lifestyle choices. The biggest problem with fibrocystic breast disease is that it will either prompt a clinician into ordering too many mammograms (too aggressive, suspecting anything) or worse, ordering too few (too conservative, blowing off one lump too many, assuming the usual fibrocystic changes). Mammograms and ultrasound are the first steps in telling the difference between lumps that have malignant potential and those, like fibrocystic changes, that don't. Risk factors for breast cancer The biggest risk factor is the genetic risk factor. A family history of breast cancer involving a sister or a mother can double the risk to a woman as well as increase the risk of developing breast cancer in both breasts.  Additionally, if the family history involves a young woman, the risk is substantially increased. If there are two primary relatives (a sister and her mother, or two sisters, for example), the risk of developing breast cancer as a young woman will increase. Even a grandmother adds to the risk.

Next in risk is the consideration of age.  As a woman gets older, her risk can increase to over ten times what it was as a younger woman.  As mentioned above, with the surviving population

The Uterine-Ovarian-Breast Relationship

The Uterine-Ovarian-Breast axis is another relationship:  If a woman has had cancer of the ovary or uterus, she's at increased risk to have breast cancer.  This probably, once again, is related to the genetic factor.

There's the "Use it or lose it" risk.  That is, women who don't use organs of reproduction (the breast included because of its ability to lactate) have an increased risk of not only cancer of the breast, but of the ovary and uterus as well.  Delaying a first term pregnancy to later in life, so much the strategy of today's career-oriented women, is associated with this increase in risk.

One controversial aspect of breast cancer is the contradiction in the effects of estrogen.  Natural estrogen, when absent because of removal of the ovaries (for other reasons), decreases the risk of breast cancer.  Yet consumption of naturally occuring estrogens, like in isoflavones (soy) will decrease the risk, too.  In fact, women with breast cancer have shown a decrease in isoflavones when compared with women without breast cancer.

Go figure.

A late menopause, with the prolonged estrogen supplied to the scenario, increases the risk.

Contrary to popular thinking, the birth control pill has not been shown to increase the risk, and may even lower the risk.

Increased dietary fat, increased alcohol consumption, breast trauma, high socioeconomic class, and obesity have also been implicated as risk factors, but no studies have definitively proven these. Artificial estrogen replacement has also been implicated as a causative factor, but the general thought today is that there is no increased risk of breast cancer secondary to hormone replacement.  (And everyone agrees that osteoporosis will definitely have its easiest way to your bones without estrogen.)

The most unsettling fact is that even without all (or any!) of the risk factors,

Pretty scary. No matter how rich, how politically correct a vegetarian diet you eat, or how famous you may be, cancer is the great equalizer.

Over half of the breast cancers are caught by the patient herself, presenting to the doctor to have a lump evaluated.  Mammograms only catch about a fifth in women without symptoms.

In the doctor's office:    Suspicious lumps are usually painless, not freely-moveable, and irregularly shaped. Alternatively, unsuspicious lumps are painful, freely moveable, and very round.

At home: Self-exam in front of a mirror or while soapy in the bath should seek out irregular dimpling. Nipple discharge should also alert a patient to trouble. The underside of the fingers, just under the finger-tips should be used, because these are the most sensitive areas to feel subtle changes. The breast tissue should be pressed against the flat chest wall (don't roll breast tissue agains breast tissue--this will normally be lumpy).

The recommendations for mammograms are fickle and are forever changing.  Currently, a baseline mammogram between the ages of 30 and 35, twice a year in a woman's 40's, and yearly after 50 are reasonable, unless altered by a worriesome family history or previous abnormality.

Anything abnormal on an ultrasound can be further investigated using ultrasound (which will tell whether a lump is a cyst or a solid collection of tissue) and compression and magnification views. Often these enhanced views will exhonorate what was abnormal on mammogram, so don't panic at the first report of an "abnormal" mammogram.

Calcifications clustered suspiciously can prompt further work up. The body deposits calcium from age, scarring, or other injuries, like cancer. Masses discovered to be cystic can be drained with a needle. Cystic masses have a low incidence of becoming cancer, but the fluid should be checked just the same. If it is straw colored, the chance of malignancy is almost zero. Darker or bloody fluid is a bad sign.  If a cyst that has been drained comes back, a doctor may want to remove it, yielding a diagnosis as well as a resolution to the problem once and for all. This is called excisional biopsy.

Fine needle aspiration is used drain cysts and get a specimen.

Cosmetic sensitivity on the part of the surgeon, usually using an outpatient facility, can investigate and remove a mass with little if any distortion to the breast.

Fibroadenomas, mastitis, breast abscesses, and milk cysts are all examples of breast conditions which are benign, but which can produce either transient or permanent breast masses. These must and can be distinguished from cancer by the above techniques.

      Breasts are very dynamic glands, evident in that most important first step for a baby, but giving life should be their only function. Unfortunately, taking life has become too frequent an outcome.

Treatment And Reconstruction

Treating breast cancer with surgery is only half the job

Treatment for breast cancer used to be a simple decision: mastectomy, i.e., removal of the breast. In the last twenty years, many alternative approaches began being studied in the literature, some of which have proven just as effective as mastectomy. Certainly "lumpectomy" sounds more conservative, but one must consider that conservation of this nature usually requires radiation therapy, too, which can have side effects that mitigate the benefits of retaining one's breast.

With one in nine women destined to have breast cancer, and 46,000 women dying from it every year, it's easy to understand the paranoia many physicians may have. This mind set will make them suggest that mastectomy may be the safest approach for surviving this terrible disease. They reason that whatever stimulus caused the breast to undergo its transformation is still there, along with the very tissue that responded to that stimulation. Since the breast is a symbol of infant nurturing as well as sexuality, paranoia goes head to head with a woman's desire to be "whole." And although reason dictates that a life is more important than a breast, still many women seek compromise in this conflict.

One such compromise is plastic surgery and the techniques of breast reconstruction after a mastectomy. With these skills, a plastic surgeon can mask the removal of an entire breast with a very natural presentation. But reconstruction of the breast needs to be considered early in any breast cancer management protocol, and the plastic surgeon should be part of the team, along with the general surgeon and oncologist.

Besides the big decision of whether to spare or to remove the breast, another consideration is whether reconstruction should be at the time of surgery or delayed until well after. The type of cancer management will determine the amount of reconstructive surgery. For instance, a lumpectomy with radiation may be imprudent in a small breast with a large lesion, because the relative size of large lesion to small breast may leave an unreasonable deformity which will be harder to correct than the total approach after a mastectomy. A large breast with a small lesion, on the other hand, tends to make a lumpectomy a good approach from an aesthetic point of view.  Any therapy, therefore, must be individualized for the size, type, and stage of the cancer, and the size and shape of the breast. But once again it must be remembered that conservation of the breast with lumpectomy usually requires radiation which can cause significant tissue changes and undesirable firmness.

Reconstruction of the breast employs innovative techniques that can use artificial implants or the more sophisticated use of the patient's own skin, fat, and muscle from the abdomen or buttocks. When a patient's own tissue is used, the result can be dramatically natural. In today's world, a woman has every right to champion her breast, either her natural one or the one reconstructed by the talents of a plastic surgeon.

Self Examinations For Your Breasts

The simple technique of the monthly breast self-exa

Once a month, preferably right after her period ends, a woman should check her breasts while bathing. Lumps are more discernible when the sensitive pads of the fingers are lubricated with soap. A woman should feel for lumps, thickenings, or other changes. She should feel breast tissue flat against the chest wall, preferably by raising the arm of the breast side being checked.

She should also examine her breasts in a mirror for signs of asymmetry, skin dimpling, and contour irregularities. The arms are placed over the head for the best inspection in the mirror.

Gently squeezing the nipple will check for a discharge, which should be reported immediately to her doctor.

By placing a pillow under the shoulder and the hand under the head, that side's breast can be examined by the opposite hand and is thorough enough to include the armpit and side of the breast.

 

Uterine cancer--A Tale of Two Lesions

 

The anatomy of the womb, or uterus, has different types of tissue.  The first consideration is that the entire structure can be thought of, both anatomically as well as functionally, as two different organs.  The body of the uterus holds the baby during a pregnancy, and when there is no pregnancy prepares for one every month by building up tissue within for an egg to implant. Each cycle, this process begins anew, sloughing the old tissue in preparation for the new tissue to be hormonally stimulated to develop and thicken. Monthly periods are the outward sign that this process is going on successfully.

The cervix is that portion of the uterus which exits the pelvis (abdominal cavity) by crossing through the back of the vagina and sitting within the vagina as an exit for menstrual tissue or babies, depending. The function of the cervix is to provide a route in for sperm and an exit out for the baby or menstrual tissue.  But it is structured in such a way as to hold the baby in for the usual amount of time that will allow for maturity before birth. For this is uses circular muscular and fibrous tissue that add strength to its closure until there is enough force (labor contractions) to force a wedge (the baby's head) through it, effecting what we call dilation. When the dilatation during labor is as wide as the exiting head, delivery occurs.

So what does all of this variation in function between these two parts have to do with cancer?

The differing functions underscore the fact that there are different types of tissue--different types of cells. This means that cancer in different types of cells are different types of cancer. When it comes to discussing cancer of the cervix and cancer of the body of the uterus, one might as well be talking about two different organs altogether.  The causes are different, the disease processes are different, the treatments are different, and the prognoses are different.

The body of the uterus is made up of three layers: a flimsy outer "serosa," a thick middle muscular "myometrium," and the monthly altering "endometrium." (Endometrium is not to be confused with "endometriosis," which is endometrial-like tissue in abnormal locations in the pelvis contributing to inflammation, pain, and possibly infertility; whereas the endometrium here is the normal innermost lining that becomes eventually menstrual tissue or the fertile bed a fertilized egg implants into.) Generally, malignancies in this part of the uterus originate either in the muscular myometrium (actually, a rare cancer called a "sarcoma") and in the endometrium (the more likely "carcinoma"). Carcinomas of the endometrium are more likely if there is a family history of this specific type of cancer.  Also, there is such a thing called the uterine-ovarian-breast axis, which is a relationship among these organs wherein having one makes a woman more likely to have one of the other types.  The survival of endometrial cancer depends on how immature the cells that form the cancer are (the more immature, the worse it is) and how deep into the muscular myometrium the cancer has invaded (the deeper it goes, the worse the prognosis).

Endometrial cells are glandular cells that line the body of the uterus but are above the cells of the cervix.  If one were to take an imaginary journey from the inside of the uterus, through the cervix, then out of the uterus altogether, into the vagina, one would see the internal endometrial cells change at some point into cells of the outer cervix and vagina.  This change is the dividing line between the figurative "two different organs" that the body of the uterus and cervix represent.  The outer cells of the cervix are made up of cells closer to vagina-like cells than endometrial cells.  For this reason, they make a different type of cancer.

Cervical Cancer

But cancer of the cervix is a different breed altogether.  First of all, it doesn't follow a family history predisposition. Instead, at least two co-carcinogens, the Human Papilloma Virus (HPV) and smoking, combine to stimulate the unbridled growth that is the property of cancers.

One aspect of smoking that gets little press is the fact that nicotine is concentrated thirty times higher in the bloodstream of the cervix than anywhere else in a woman's body.

Although it's true that some cervical cancers occur even in the absence of these two carcinogens, the deck is nevertheless stacked against the cervix when one or both are present.

No one quite knows why women develop endometrial cancer of the body of the uterus.  So this is a major differing aspect of cervical cancer in that it has a sexually transmitted cause (HPV) and an environmental cause (smoking).  Other differences include the following:

Cervical cancer is typically a disease of younger women, due to the likelihood of multiple sexual partners in this group as opposed to older women who are more than likely to be involved in monogamous relationships. The more sexual partners, the more likely that a woman will make contact with "Mr. Wrong," who harbors HPV. Endometrial cancer is more likely in older women, typically in the 50s and 60s.  Endometrial cancer is more likely in women who have had other types of cancer in the uterine-ovarian-breast axis, whereas cervical cancer has no such associated risk.  The cure rate of cervical cancer is dependent on the amount of spread, whereas the cure rate for endometrial cancer is dependent not only on the amount of spread, but to what degree the cells are immature.

The diagnostics also differ.  When a woman presents with irregular bleeding, bleeding after menopause, or a change in menstrual amounts or timing, the endometrial lining can be evaluated by a simple in-office Endometrial Biopsy (EMB) or by the more extensive Dilatation and Curettage (D&C).  The EMB is nothing more than passing a small flexible straw up through the mouth of the womb to drag back and retrieve tissue for study.  The D&C requires an anesthetic so that the entire uterine lining can be scraped for study. It is considered more thorough, especially when used with a hysteroscope at the same time, which is a small lighted scope that looks into the womb (thorough the cervix--no incisions) before the scraping.  But although the D&C is more thorough, it is also overkill in a lot of cases.  Many studies suggest that an EMB, when combined with measurements of the thickness of the endometrium by ultrasound, approach the accuracy of the D&C in many situations.  This means that, although the gold standard is still the D&C, there are many women who can get by with less--especially the younger women.

Endometrial cancer can be eliminated with surgery, which involves at least a hysterectomy.  In advanced cases, radiation and radical surgery may be necessary.  But in borderline cases, simple medicine (hormones) can sometimes reverse the condition, which is a treatment used on the pre-cancerous versions of this lesion, called "endometrial hyperplasia.."

Unfortunately, there is no such "medical" approach to cervical cancer.  Pre-cancerous lesions (called "dysplasia") need to be destroyed (lasering, excising, or freezing), but in limiting these destructive processes to the tip of the cervix where the lesion is, childbearing can continue.  Advanced lesions involve surgery (hysterectomy), even radical surgery, but up to a point, beyond which radiation is used in the place of surgery.

These two tissue types in particular really do make one think of two different organs.  When a woman says her mother had "female" cancer, more information is needed.  The pap smear can screen for abnormal tissue of the cervix, and a deeper EMB can screen for endometrial abnormalities of the body of the uterus.  Obstetrician-gynecologist have traditionally led split medical personalities , dealing with the two aspects of the female gender, pregnancy and the non- pregnant female; so we're not uncomfortable with dualities like the two most frequent cancers of the uterus.

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