Types of Cancer
Prostate Cancer
Cancer of the prostate is the most common cancer in men in the United States. The disease occurs more frequently after age 45. Early prostate cancer may be discovered by rectal examination during a physical checkup or the cancer may cause the prostate to enlarge, producing the same symptoms as a benignly enlarged prostate. About half the men found to have cancer of the prostate have an early form of the disease that has not spread outside the prostate gland. If the cancer is not discovered at an early stage, it might spread to another part of the body.
A blood test along with a rectal examination may indicate the possible presence of prostate cancer. The blood test used to detect prostate cancer is called a prostate specific antigen or PSA. If cancer of the prostate is suspected either during a routine physical exam or because of the presence of urinary symptoms, the patient's primary care provider may refer him to a urologist (a specialist in urinary and genital diseases).
The urologist may recommend a biopsy of the gland in which a small sample is removed for examination. This is usually performed with ultrasound guidance. If the biopsy shows that a cancer is present, further tests such as CT scan or radioisotope bone scan may be performed to look for cancer that has spread.
Treatment Options
Men facing prostate cancer now have several choices when it comes to their treatment. The man's age, his general health, how much importance he places on preserving sexual function and whether the disease has spread are factors in determining the choice of treatment.
When the disease has not spread further than the prostate gland, there is a high chance of cure with surgical removal of the entire prostate gland or radiation therapy. Complete removal of the prostate gland offers the highest cure rate.
Another option for prostate cancer patients is external radiation. Low-dose radiation treatments are given daily for approximately seven to eight weeks.
The newest treatment for men with prostate cancer caught in the early stages is called radioactive seed implantation therapy. This treatment involves implanting approximately 100 tiny radioactive seeds in the prostate gland where they destroy cancerous cells while leaving healthy tissue intact. This FDA-approved procedure has proven as effective as other prostate cancer treatment options, such as surgery or external radiation therapy.
Prior to the implantation procedure, the patient visits the urologist and radiation oncologist for an initial consultation and planning study. The planning information is then used by the radiation oncology physicist and dosimetrist to plan the implant and order the seeds. The actual implantation procedure is done using ultrasound to guide the placement of the seeds in the prostate gland. The seeds are distributed evenly throughout the gland to deliver radiation in a highly-targeted way.
Each seed contains low-grade radioactive material, either Iodine-125 or Palladium-103. The radioactive substance is sealed in a tiny metallic case and the seeds remain in the prostate after they become inert (expend all of their energy). These inert seeds do not cause any long-term side effects.
Compared with other methods of treating prostate cancer, the radioactive seed implant therapy has few side effects. Most men can resume normal activities within a day or so, although some may experience side effects, such as more frequent urination or impotence. These symptoms are usually temporary and disappear over time or with medication.
By age 80 a majority of men are found to have a small prostate cancer, if tested. In most of these cases, however, the cancer causes no symptoms and requires no treatment. Since prostate cancer may develop very slowly, these elderly patients may choose "watchful waiting" instead of one of the curative therapies. In patients whose life expectancy is five years or less, the best treatment may be conservative management such as observation or hormonal therapy.
Choosing a Treatment
When faced with prostate cancer, men should discuss all of the treatment options -- radioactive seed implantation, surgery, hormonal therapy, external radiation and watchful waiting -- with a specialist. It is sometimes helpful for prostate cancer patients to bring a family member along for the initial visit with the urologist and to consider obtaining a second opinion from a radiation oncologist to discuss treatment options. At that visit, the patient and/or family might wish to ask the following questions:
* Is the cancer localized to the prostate gland or has it spread to other organs?
* Will there be a biopsy of the tumor? If so, what does this show?
* What are the options for treatment? What are the potential risks and complications of each? What are the benefits of each?
* Given the patient's age and other medical conditions, what does the doctor feel is the best option?
By discussing these and other issues, the patient, his family and his physician can make a decision that best suits his specific circumstances, concerns and needs.
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Breast Cancer
Breast cancer is the most common cancer among women, causing more than 40,000 deaths per year in the United States. Mammography, which is soft tissue x-ray study of the breast, detects cancers that can't be felt. These small cancers are cured in more than 90 percent of women. Mammography causes only minor discomfort in the vast majority of women and is associated with just tiny amounts of x-ray exposure. It is now clear that mammography is saving thousands of lives per year.
Recent controversy surrounding mammography has centered around the question of when a woman should begin screening mammography. Specifically, there were differing opinions about whether screening should begin at age 40 or age 50. During the past month, the National Cancer Advisory Board of the National Cancer Institute has substantially resolved this controversy by issuing recommendations that closely match those of the American Cancer Society. Both the Advisory Board and the American Cancer Society now recommend that women first have mammography at age 40 and every year or every other year depending on their particular breast cancer risk until age 50. For women age 50 to 65, the standard recommendation is for mammography every year. Beyond age 65, women should have a mammography every year or every other year, again depending on their individual risk factors.
It is important to point out that these basic guidelines apply to women with average risks for breast cancer. Women at increased risk because of positive family history, a personal history of breast cancer, or difficulty in either clinical or mammographic examination of the breast, may need to start mammography earlier or have more frequent mammograms. A woman should discuss these factors with her primary care provider to determine the best mammography schedule based on her risk level.
In addition to mammography, there are two other important strategies for early detection of breast cancer. Breast self-examination has also been in the news recently with questions raised as to whether it actually saves lives. Historically, most breast cancers have been detected by the woman herself, and it is important to remember that some cancers aren't seen by mammography. Therefore, the American Cancer Society recommends that at age 20 all women who are willing and able should be taught breast self-examination and they should carry it out on a monthly basis for the rest of their lives. We strongly concur with this recommendation.
The other important strategy in detecting breast cancer early is regular breast examination by a skilled health care provider. The American Cancer Society recommends clinical breast exam every three years between the ages of 20 and 40 and every year beginning at age 40.
It is worth emphasizing again that the guidelines summarized above apply to women with "average" risk of breast cancer. Risk factors that might dictate more intensive early detection strategies include:
* family history that includes breast cancer or certain other cancers (for example, ovary)
* personal history of breast cancer
* first child birth at age 30 or older
* breast examination that is difficult because of cysts or for some other reason
* or two or more previous breast biopsies for benign disease.
Reviewing these matters in detail with the woman's health care provider is an important part of every woman's health care.
Breast cancer can be cured consistently when detected early. Breast self-examination, regular clinical examination by health care provider along with review of risk factors and mammography are the critical tools for early detection. Breast self-examination should begin at age 20 and be done monthly. Clinical breast exams should be done at least every three years between ages 20 and 40 and every year starting at age 40. Mammography should be done first at age 40 and every year or two years until age 50 after which it should be done yearly until at least age 65. Women with more than average risk of breast cancer need to work with their health care provider to develop a more aggressive early detection strategy.
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Ovarian Cancer
There is still much controversy as to the proper way to screen women for ovarian cancer, especially when a single case of ovarian cancer appears in a family.
Fortunately, ovarian cancer is not as common as breast cancer. Ovarian cancer occurs in one in 70 women in the general population. There are two basic types of ovarian cancer: early stage disease with potential for cure and late stage disease with a poor prognosis. The goal, as with all types of cancer, is to find ovarian cancer early in the disease process, when it is more curable.
Unfortunately, we don't have good, reliable, reproducible tests for mass screening of the population for ovarian cancer, as we do with mammograms for breast cancer and the Pap smear for cervical cancer. Screening is the process of testing the population for early disease in people who have no sign of the illness in question. To be useful, screening tests must detect early, curable stages of disease and not result in unnecessary testing of people who do not have the disease.
So, what does a woman do when her grandmother or mother or sister is diagnosed with ovarian cancer? She should see her health care provider and inquire about her personal risk to develop ovarian cancer based on her newly diagnosed family history, her own reproductive history and her lifestyle risks. She should also discuss with her health care provider the current screening tests used to detect ovarian cancer. This last topic of discussion may cause some concern among women because of the lack of good, reliable screening tests for ovarian cancer. Unfortunately, the development of new, accurate tests or screening tools for ovarian cancer doesn't look very promising for the near future, either. Only a small portion of ovarian cancers occur as a family disease and those are the family members we try to target for our screening.
To date, the available tests for screening include:
1. Pelvic exam at yearly physical examination
2. Ca 125 blood test
3. Pelvic ultrasound, including color imaging techniques
4. BrCa 1 and 2 gene testing
However, there are problems with each of these screening tools to find ovarian cancer early. The pelvic exam will often miss early cancers because an ovary with cancer in it may not feel any larger than the normal ovary to the examiner. Therefore, pelvic exams done even as often as every six months have not proven useful in finding ovarian cancer early.
The Ca 125 blood test is even more of a disappointment than the pelvic exam as a screening test. More than 50 percent of all ovarian cancers do not produce the chemical that is detected with this test. Therefore, the test can come back negative and, yet, the patient actually has ovarian cancer. This is what makes it a particularly bad test, because the patient and health care provider are given a false sense of security. In addition, many times this test can come back with abnormal results in cases where the patient has a benign (not cancerous) condition. This is called a "false positive" test. Many times, a "false positive" leads to surgery for suspected cancer that does not exist. The only good use at this point in time for the Ca 125 test is for patients with known ovarian cancer and a high Ca 125 level. The Ca 125 level then becomes what is called a "tumor marker" to tell us if the ovarian cancer that has been completely removed at surgery or with chemotherapy has come back (recurred). For example, if a patient with known ovarian cancer has a Ca 125 of 4000 initially and falls to 25 after treatment, and then rises to 200 two years later, that may indicate that the cancer has come back.
The next test, ultrasound, uses sound waves to bounce off structures in the body. If a cyst is found in the ovary on exam, ultrasound may tell us if it is possibly a cancer. But, like the Ca 125 blood test, ultrasound also has its limitations and is not useful as a mass screening test because it is not easily and routinely administered to large numbers of people.
Also included is the possibility of testing for ovarian cancer via genetic screening (BrCa 1 and 2 genes.) Currently, these tests are used in very well defined circumstances, often allowing us to identify people who are at higher risk than the general population to develop ovarian (or breast cancer or other types of cancer). Genetic screening is not really a true screen; it's more a potential identifier of people at risk, especially those people who have a family history of early age onset breast cancer or bilateral breast cancer (separate cancer in each breast in one person).
Finally, if you have questions about ovarian cancer -- even if there is no history of it in your family -- please seek advice from your health care provider. He or she can provide you with the most up-to-date, comprehensive information about screening methods appropriate for your circumstances.
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Radiation Treatment Planning System
Bassett Healthcare's radiation oncologists currently use a three dimensional, computerized treatment planning system in providing radiation therapy to cancer patients at the Louis Busch Hager Cancer Center in Cooperstown. The system allows radiation oncologists and dosimetrists (treatment planners) to better target cancerous tumors, allowing for more precise treatment and less damage to surrounding healthy tissue than previously possible through two-dimensional planning.
With the system, dosimetrists and radiation oncologists take information from numerous CAT scans (computerized axial tomography scan) of the affected area and calculate, in three dimensions, the precise location of the area to be treated. Because the tumor's size and location are mapped in three dimensions, the path of the radiation beams can be better targeted toward the tumor, especially important when cancerous calls are located in sensitive or complex body areas, such as the prostate, brain, breast and esophagus.
"This treatment planning capability allows us to provide a high level of care to our patients," said Bud Zaengle, the Bassett Healthcare dosimetrist responsible for designing radiation therapy treatments, as well as the blocking and shielding needed to protect healthy cells.
The ability exists to include the rotation of the treatment table. This allows for radiation to be given at different angles and at higher doses while sparing more of the normal tissue. The purchase of this system further demonstrates the commitment of the department to provide the latest capabilities in cancer care.
For more information on the cancer treatment services available at Bassett Healthcare's Regional Cancer Program call (607) 547-6680 or (800) 939-0090.
