Doctordenky's Blog

When relatives do not want me to tell the patient that he has cancer, I use the words “tumor” or “malignant” or “bukol” or “cancerous” to describe to them what they have.

When patients hear the word tumor, it always sends shivers down their spine. A tumor is often associated with cancer but NOT ALL TUMORS ARE CANCER. However, most cancers manifest in the form a tumor.

A tumor simply means a new growth or growing mass in the body. A tumor is not always synonymous with cancer. It simply means that there is something growing in the patient’s body.

A tumor can be BENIGN or MALIGNANT. It means that a tumor can be a cancer or not. A benign tumor is never malignant and a malignant tumor is never benign while a malignant tumor is always cancer and a cancer is always malignant.

A benign tumor is similar to a malignant tumor in the sense that both are forming a mass which is growing in the patient’s body. However, a benign tumor remains in its original place where it started growing, it does not metastasize or migrate to other parts of the body, it does not invade or infiltrate other structures and is rarely life-threatening. A malignant tumor is the opposite of all these things.

A benign tumor is always managed by surgery but it often ends after that. After a benign tumor has been surgically removed, there is usually no follow-up treatment necessary while malignant tumors/cancer may require several modalities of treatment such as surgery, radiation therapy, chemotherapy, hormonal therapy and targeted therapy.

A benign tumor is not cancer but a malignant tumor is. Benign is not a term that we use to describe cancer. Instead, we use malignant.

Can a benign tumor transform to cancer or become cancer at a later time? It can but not very often.

Cancerous is a term which is in-between. It is a term that is resorted to by doctors who do not have the courage to tell the truth or patients who have not yet quite accepted what they have. Cancerous is when a tumor has gone beyond benign but not yet definitely cancer. It has a greater tendency to evolve into cancer and has to be monitored very aggressively.

In a previous post, I have discussed the signs and symptoms of cancer (Understanding Cancer Series: Signs and Symptoms of Cancer). Different patients will have different manifestations. They will have different reasons for going to the doctor. What is important is that when the condition has been lingering for two weeks or more, the patient should see a doctor as soon as possible.

How are Diseases Diagnosed?

Once you see your doctor, he will first get a thorough history (ask you to tell the story of the problem that caused you to see him then ask additional questions). Once he is already satisfied with the initial information, he will proceed to perform a physical examination on the patient and often request for laboratory exams.

A patient’s problem may not be immediately obvious to the doctor even after laboratory tests. This is especially true if the problem lies deep inside the body and nothing is obvious on the surface or if the patient’s symptoms are not typical of the underlying disease. The initial tests can sometimes not reveal anything. This does not always mean that there is no problem. The doctor may ask for additional tests or tell you that there is nothing wrong. Just by seeing patients, we can sometimes already tell whether something is terribly wrong or the problem is only minor. So if we see that the patient is quite ok, we can just tell the patient to observe the problem because some problems go away even without treatment such as some types of diarrhea or the common cold.

Getting a Second Opinion

Whenever I tell my patients that there is no intervention necessary, I always tell them when I expect the problem to have completely resolved and that if the problem persists, it means that we need to do further investigation. I also inform them to come back even before scheduled follow up if the problem gets worse or if a new problem arises.

I ask them to let me know whatever happened to the problem, whether good or bad, to make sure that the problem does not blow out of proportion. However, if you are not a hypochondriac (one who interprets minor illness as serious and life-threatening conditions) and you feel that your condition should be looked into some more and it is being ignored, let your doctor know this. If he doesn’t want to listen to you, there is nothing wrong in getting a second opinion.

Additional Tests

The initial tests requested by a doctor are often only to screen for problems that he suspects based on the information at hand. Quite often, we need to do additional tests such as ultrasound, CT scan, MRI, endoscopies to give more detailed and more accurate information.

Cancers, except leukemia, are always associated with a mass anywhere in the body, sometimes easily evident but sometimes hidden in the nooks and crannies of the body. Even when we see the mass, we can never definitively tell that it is cancer without performing a BIOPSY. A BIOPSY is a procedure wherein a portion of the mass is removed in order to further evaluate it through the microscope or additional tests. The doctor who does the biopsy is almost always a SURGEON or an INTERVENTIONAL RADIOLOGIST and the doctor who evaluates the specimen is a PATHOLOGIST.

Types of Biopsy

There are different ways of doing a biopsy. I will divide them according to where the tumor is located. Tumors that are located at or near the body surface are easily accessible and don’t need elaborate techniques to perform the procedure. The following are the biopsy procedures employed:

a. Fine needle aspiration biopsy
b. Core needle biopsy
c. Excision biopsy
d. Incision Biopsy

Tumors that are hidden inside the body need special procedures to carry out the biopsy. Again, the objective is to get a piece of the tumor for analysis. The procedures include:

a. CT scan-guided aspiration biopsy
b. Endoscopic-guided biopsy
c. Laparoscopic biopsy
d. Thoracoscopic biopsy

In a previous post (Understanding Cancer Series:  What are the Signs and Symptoms of Cancer? Part 1), I have given reasons why cancers may present very early or late in the course of the disease.  We also know that the signs or symptoms vary depending on the location of the tumor.

There are clues, however, that should alert a patient to consult a physician.  NOTE: THESE SIGNS OR SYMPTOMS ARE NOT SPECIFIC TO CANCER.  THEY CAN BE FOUND IN SITUATIONS OTHER THAN CANCER BUT SHOULD, NEVERTHELESS ALERT THE PATIENT TO SEE A DOCTOR.

Remember the acronym CAUTIONUS which means the following

1. CHANGE IN BOWEL OR BLADDER HABITS. A tumor may obstruct the large intestines and cause the patient to become constipated.  Patients often describe conditions like pencil-like stools or very small stools similar to goat-stools (marble or quail egg sized stools).  Sometimes, constipation can be replaced by periods of diarrhea then revert back to constipation again after the diarrhea has resolved.  Any changes in bowel habits, especially if prolonged or associated with weight loss or lack of appetite should prompt consultation
2. Changes in urine, especially bleeding or changes in color especially if accompanied by back pain should prompt consultation.
3. A SORE THAT DOES NOT HEAL. A sore in the mouth or on the skin, even if not painful, should prompt consultation.
4. UNUSUAL BLEEDING OR DISCHARGE. Bleeding can happen in any part of the body such as from the nose, the lungs (blood-tinged phlegm or significant amounts of blood in the phlegm), vomiting of blood or presence of black feces, blood-tinged feces or profuse bleeding, prolonged menses, re-appearance of menstruation after menopause, inter-menstrual bleeding, blood in the urine, bruises on the skin especially in the absence of trauma, bleeding or discharge from the nipples.
5. THICKENING OR LUMP IN THE BREAST OR ELSEWHERE. Tumors generally form masses that can be felt if they are on or near the external surface of the body.  More caution if the mass is very hard.
6. INDIGESTION OR DIFFICULTY IN SWALLOWING. Patients may experience difficulty in swallowing solids initially then liquids if there is a mass in the esophagus.  Symptoms may also be as non-specific as indigestion, bloatedness or ulcer-like pain.
7. OBVIOUS CHANGE IN A WART OR MOLE. Changes in the color, size, consistency, sudden presence of itchiness of moles can signal the need for consultation especially for fair-skinned people and if on sun-exposed areas of the body.
8. NAGGING COUGH OR HOARSENESS. Cough occurs in all ages and is one of the problems many of us often encounter.  However, if the cough is prolonged or associated with weight loss, absence of fever, blood in the phlegm may signal the patient to seek consultation.  Suspicion is heightened if the patient has a significant smoking history or exposure to second hand smoke.
9. UNEXPLAINED ANEMIA. This may be an early manifestation of cancer or something else
10. SUDDEN UNEXPLAINED WEIGHT LOSS. Weight loss that is due to intentionally less food intake does not count.  However, weight loss despite adequate food intake or weight loss associated with unexplained loss of appetite should signal some concern.

What are signs and symptoms?

Signs and symptoms are what doctors use in figuring out what could possibly be wrong with a patient.  When patients go to doctors, they often report changes that they or other people have noticed about them by telling their story.  We call this process history taking and more than laboratory tests, history taking is the most important step in finding out the patient’s problem.

Signs and symptoms often, but not always, signal that they there may be something wrong with a patient.  A SYMPTOM is something that is felt by the person who has them while a SIGN is something which is noticed by another person.

Examples of Signs and Symptoms

THERE ARE NO SIGNS AND SYMPTOMS THAT ARE SPECIFIC FOR CANCER.

This is often a double-edged sword.  The good thing is that not because a person has any of the common signs and symptoms of cancer means that the patient has cancer.  However, because these signs and symptoms may not be unusual at all, many patients may not be alerted that there could be something wrong because they dismiss the problem as simple.

Signs and symptoms of cancer depend on several factors

-       its location

-       size

-       whether it has already affected other structures or not

-       whether the cancer has already migrated to another part of the body.

Some patients may present with early stages of cancer (and therefore be still curable) while others may present with already advanced stages of cancer (may not be cured anymore but not always).  One question that has often been asked of me is “Why did it happen so quickly?”

The Man Who Dropped in Front of the Audience

A man in his 60’s was rushed to the emergency room.  While delivering his speech, he suddenly stopped, rolled his eyes upward, fell on the floor and started convulsing.  He suddenly developed a seizure (more commonly known as an epilepsy) and remained unconscious.  A CT scan of the brain was done revealing, the patient was noted to have a large mass in the brain likely to be a tumor.

On further testing, he was noted to have a tumor in the lungs.

A biopsy of this tumor revealed it to be lung cancer.  The tumor in the brain is likely a metastatic lesion (lung cancer that has migrated to the brain.  This patient does not have lung and brain cancer simultaneously.  His lung cancer has already metastasized/transferred to his brain which puts him in the category of Stage IV lung cancer).

“Why Did Everything Happen So Quickly?”

This patient’s cancer did not happen quickly.  Cancers generally take years to develop and grow.  It is unfortunate that the patient only developed symptoms very late in his disease (when the cancer has already transferred).  The reason is that the patient’s tumor in the lungs was located in an area where there is a lot of room for expansion.  His tumor did not impinge on any structure to cause any sign or symptom such as cough or pain.  The tumor in his lungs probably existed for several years but was not bothering him until it has already migrated to the brain.  The presence of the tumor in his brain stimulated the brain cells enough to cause him to develop a seizure.

Signs and symptoms of cancer can mimic those of common and innocuous problems.  Some cancers may grow in the body without any manifestations at all.  Organs such as the stomach, large intestines and lungs have a lot of room to accommodate the cancer allowing them to remain silent for a very long period.  At other times, some tumors are just so aggressive that even while they are still very small, they are already growing simultaneously in another part of the body and they produce symptoms only when in this other location.  This is what happened to the above patient.

On the other hand, there are tumors that can produce signs and symptoms while they are still very small.  A small tumor may cause bleeding in any part of the body if it is eroding a blood vessel or it may cause pain if it is impinging on nerves.  A patient with tumor in the large intestines can present with blood in the feces.  A small tumor in the neck may also be readily noticed because it can bulge early on.  A small tumor in the brain can cause a mimic a patient having a stroke.

Nowadays, there is rarely a person who has not been touched by cancer.  Someone close to you, a loved one, a friend, a co-worker or through the stories we encounter via media make it seem like cancer is everywhere and it can really scare us.  Cancer has such a stigma that almost everybody thinks it is the always end of the world for someone who is afflicted.  In my clinic, the most common questions asked beg for an explanation to help ease the pain.  Questions like “How did it happen?”, “What caused this cancer?”,  “How come it happened so quickly?”, “Can my family get infected with this disease now that I have it?” are often thrown at me.

I always go through great lengths to help the patient and family understand what is happening no matter how many times it is necessary to repeat the same things.  I may not always cure the patient but I know that by being patient and understanding, I can somehow give comfort.  Knowledge is power and it often makes a big difference in the patient’s and family’s journey.

So what is cancer and where does it come from?  In order to understand what cancer is, we first need to understand what is normal.

All of us, embryos, children, teens and adults are made up of cells.  In science books, we give the cell credit as being the basic functioning unit of the body.  Cells are not visible with the naked eye.  We need a microscope to see them.  However, they are powerhouses.  They enable us to be who we are and to be literally alive.

A fantastic thing about cells is that they have a definite lifespan.  Like everything in life, they are also subject to wear and tear.  But nature is all-giving.  It has enabled man to live a very long life without the constant need for repairs.  Nature has programmed the normal cell to die after serving its useful time but it has made sure that before the cell dies, it must first give rise to new cells (the process is called MITOSIS) that will take over the function.  In this way, survival of the organism and optimum performance are ensured.

Whereas birth of the new cells is ensured, death of the old cells must also be certain.  This is called programmed cell death or APOPTOSIS.  If this does not happen, there will be an overgrowth of cells that can impair the functions of the body.  This is actually one of the problems in cancer.  Some of the old and damaged cells become stubborn and don’t die as they should.  This usually happens when the normal cells have undergone a series of changes (MUTATION) that have transformed them into nasty elements that no longer obey the laws of the body.  They continue to multiply unabated and rapidly.  They migrate to other parts of the body (METASTASIZE) or invade surrounding structures.  These are the hallmarks of cancer.  They grow endlessly and destroy the organism.  They interfere with the normal functions of body parts and compete with normal cells for nutrients causing the body to loss weight and become weak.

So what causes these normal cells to transform and develop cancer?  The body has a mechanism that enables itself to repair damages here and there.  Cancer develops when the body’s capacity to repair itself has been overwhelmed by constant damage.  There are instances, however, when a patient may develop cancer because he is carrying the genes (heredity) that predispose him to the condition.  Sometimes, just carrying the cancer gene may already cause a patient to develop cancer.  However, not because a person has the genes for developing cancer will automatically make him have the disease.  Patients can lower this risk by maintaining a healthy lifestyle especially avoiding smoking.  Alternatively, the patient can undergo cancer screening to detect the cancer while there are no symptoms allowing us to detect the cancer at a very curable stage.

There is no single factor that causes of cancer.  The truth is, we do not know exactly what causes cancer.  However, we know that there are certain things that can increase a person’s chances of developing the disease.  The causes are multifactorial and involve an interplay of genes or heredity, lifestyle, chemical exposure (such as asbestos, industrial solvents), radiation (exposure to nuclear plant explosion), viruses (Human papilloma virus or HPV, Hepatitis B virus) and of course SMOKING.