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Selasa, 01 Januari 2008

CERVICAL CANCER VACCINE . GIRLS......TIME FOR GET THAT....



Cervical cancer vaccine
Written by Dr David Delvin, GP


© PhotoDisc
Vaccines protect against the types of HPV that cause most cases of cervical cancer.
2007 heralded the arrival of two new vaccines to prevent cancer of the cervix (neck of the womb): Gardasil and Cervarix. They both work by protecting against the human papilloma virus (HPV) that causes most cases of cervical cancer.

What is cervical cancer?

Cervical cancer is the second most common malignancy among women worldwide, with about 500,000 cases a year. In developing countries it is the main cause of cancer deaths in women, and around 250,000 women die each year because of it.

In the UK the national smear testing service that screens for HPV has led to a great decrease in the number of deaths from cervical cancer. In 2006 around 1000 women died from cervical cancer, mainly because they did not attend smear tests.

The main risk factors for cervical cancer are:

* smoking

* living in a poor area (cervical cancer is more common in the north of England than in the affluent south)

* a partner who has a manual job

* having started sex early in your teenage years

* having multiple sex partners

* multiple pregnancies.

But any woman who has ever had sex is at some risk of cervical cancer.

What is HPV?

Human papilloma virus (HPV) is a virus that is passed on by sexual activity. It needn’t be actual sexual intercourse: HPV can also be transmitted by deep petting (genital love play).

It's thought more than 80 per cent of British females get HPV at some point in their lives. But what usually happens is the virus doesn’t cause a cancer, and after some time the body eventually defeats it and gets rid of it.

There are more than 100 types of HPV. Some types of HPV are associated with genital warts. Others are linked to cancer of the vulva, vagina, anus, penis and throat.

Only a few types – notably numbers 16 and 18 in the UK – are capable of producing cervical cancer. It usually takes 20 years or more for cancer to develop.

The peak age for cervical cancer in the UK is 35 to 40, though you can get this type of cancer well into old age.

How can you tell if you have HPV?

HPV does not produce symptoms when you get it, so you have no way of telling whether it is present in your body unless you have a smear test.

Pap smear tests should detect the cancer long before it produces any symptoms. If HPV is detected by a smear test, it can usually be treated and cured. As a rule, this will be long before it can do you any harm.

What are the new vaccines?

There are two new vaccines against HPV: Gardasil and Cervarix.

Gardasil has been licensed in over 75 countries, including Britain. It works against HPV types 16, 18, 6 and 11. These strains of virus cause most of the cases of cervical cancer in the UK, so if given early enough Gardasil would prevent the majority of these cases.

But because it doesn't protect against all strains of HPV, it cannot prevent all cervical carcinomas. It also gives some protection against genital warts that are also caused by HPV.

The other vaccine, Cervarix, has been approved by the health authorities in Australia and is awaiting approval in America and the UK. It protects against HPV types 16 and 18, but no others. So again, it cannot offer a woman 100 per cent protection against cervical cancer.

How are they taken?

Both vaccines are given as a course of three injections, over a period of about six months.

How long does protection last?

At the moment, we know that the protection offered by the vaccines lasts at least five years. Nobody can yet say whether it will last for life.

Are there any side-effects?

Like virtually all medications, the two new vaccines can have side-effects. While these don’t appear to be serious, it’s possible that more significant side-effects might emerge in the long term, as is the case with any new treatment.

At present, the most common adverse effect is soreness at the injection site, which is not a major problem. The jab can also cause skin irritation and slight fever.

Rare ill-effects include joint pain and the skin eruption called urticaria (hives). Very rarely, the jab can cause wheezing.

It is not known whether the drug will be safe for use during pregnancy. Certainly, no pregnant woman should consider having it at present.

Who should have the vaccine?

Currently, health authorities regard these vaccines as a preventative measure, so the focus is on giving the vaccine to young teenage girls well before they start having sex. In Australia there are plans to give it to teenage boys.

In Britain the vaccination will be offered to all 12 and 13-year-old girls from September 2008. In autumn 2009 a two year catch-up campaign will start for girls up to 18 years of age.

Adults and the vaccine

Many women have read newspaper reports about the new vaccines and thought it would be a good thing for their health.

But there seems to be little point in an adult woman having the jab. Why? Because it’s probably too late to protect against the HPV virus, which may well have entered your body years before.

For the moment, adult females should continue to rely on Pap smear tests to protect them from HPV. It seems probable that this will be so for at least the next 20 years.

A case could perhaps be made for administering it to a woman who is a virgin, but who is now planning to embark on an active sex life. The same could be said of a woman in her early twenties who has had very little sexual activity so far.

In practice, if you are an adult it is very unlikely that your GP could get approval for giving you the vaccine - or would even want to get it. The jab is expensive, costing about £80 a dose.

If you really want the vaccine, your only option is to go private - if you can find a gynaecologist who is willing to administer it.

You may be surprised to hear that some adult males have gone to private doctors to get the vaccine. These are gay men, who want to try to protect themselves against genital warts and possibly anal cancer.

What about objections to the vaccines?

In the USA there have been quite vociferous moral objections to the use of the vaccine in the early teens. This is because it is felt by some people that giving teenagers the jab is equivalent to handing them permission to have sex.

In Britain recent surveys have shown that about three quarters of parents would be pleased for their daughters to have this jab, once they realise its purpose is to prevent cancer.

Will the vaccines eradicate cervical cancer?

One of Britain’s greatest experts in the field of cancer-causing viruses, Professor Margaret Stanley, says the introduction of the vaccines 'really does look like the beginning of the end for HPV-associated disease in women'.

However, Professor Stanley is open about her possible bias as a consultant for the firms that make the vaccines.

Other experts believe the many types of HPV are so rife, women are going to need to continue to have smear tests well into the 21st century.

Do you still need to go for smear tests after having the vaccine?

Even if you have the vaccine, you must continue attending for regular smears. This is because the jab cannot protect you against all strains of HPV.

HPV has no symptoms - so don’t think 'I haven't got any symptoms and I feel perfectly well, so I don’t need smear tests.' You do.

Similarly, if your 12-year-old daughter is given the vaccine, she too will need to have smear tests throughout her adult life.


Last updated 01.11.2007

SMOKING TO MUCH ...CAUSE LUNG CANCER, SO STOP FROM NOW


Lung cancer
Reviewed by Dr Gavin Petrie, consultant chest physician

What is lung cancer?


© NetDoctor/Geir
Lung cancer is one of the largest killers in the Western world. The risk of developing lung cancer is increased 10-40 times if you smoke.
The cells of all living organisms normally divide and grow in a controlled manner. Cancer results when this control process is lost. A lump or tumour, known as the primary tumour can grow locally or spread to produce secondary tumours somewhere else in the body. This spreading process is called metastasis.

About 40,000 people in the UK die every year from lung cancer. It is the most common form of cancer in the UK and the most common cause of death from cancer in both men and women although it affects more men than women.

What causes lung cancer?

Tobacco smoke is the primary cause of lung cancer. Although nonsmokers can get lung cancer, the risk is about 10 times greater for smokers and is also increased by the number of cigarettes smoked per day.

If you are a heavy smoker consuming more than 20 cigarettes a day, the risk of developing lung cancer is about 30 to 40 times higher than if you don't smoke.

The main reason for the substantial increase in the disease over the last 50 years has been the increase in the number of people who smoke cigarettes. This has resulted from the industrial production and marketing of tobacco.

The risk of lung cancer in an ex-smoker falls to the same level as a nonsmoker after about 15 years.

What are the symptoms of lung cancer?

The symptoms of lung cancer include:

* a chronic cough.

* worsening breathlessness.

* weight loss.

* excessive fatigue.

* persistent pain in the chest or elsewhere, (possibly from the cancer spreading to a bone).

* symptoms can be due to the original tumour in the lung or to the effects of secondary tumours elsewhere in the body.

* one of the most significant symptoms of lung cancer is coughing up blood or haemoptysis. This can sometimes occur as an early warning sign of a cancer which may still be curable. Any person who coughs up blood should see their GP for advice urgently as lung cancer must be considered, particularly if the person is a smoker over the age of 40.

How is lung cancer diagnosed?

Sadly, most lung cancer is diagnosed too late for curative treatment to be possible. In over half of people with lung cancer the disease has already spread (metastasised) at the time of diagnosis.

Early diagnosis is difficult because many of the common symptoms of lung cancer are similar to those of smokers' lung (chronic obstructive pulmonary disease or COPD).

In addition to this, most lung cancer patients will also have COPD because both conditions are mainly caused by smoking. However, only 1 or 2 per cent of COPD patients will go on to develop lung cancer.

The first investigation is a chest X-ray. If a lung tumour is present, it needs to be at least a centimetre in diameter to be detectable by an ordinary X-ray. However, by the time a tumour has reached this size the original cell which became cancerous has divided (or doubled) 36 times. As death usually results after 40 such cell divisions, it is clear that lung cancer is a disease that is usually detected late in its natural course.

Some simple blood tests and further examinations may also be carried out.

Bronchoscopy is direct inspection of the inside of the breathing tubes with a thin fibre-optic instrument using local anaesthetic and is the best test for tumours in the main bronchi (air passages) in the centre of the chest.

Depending on the site of the cancer, a biopsy will be obtained either by a bronchoscopy or a needle biopsy. Needle biopsy is better for cancers near the periphery of the lungs (ie closer to the ribs than the centre of the chest), beyond the reach of the bronchoscope.

Usually, a sample of sputum - the material coughed up from the respiratory tract - will also be examined for cancer cells and this can avoid the need for biopsy.

A CT scan provides more information about how much the tumour may have spread.

There are three main types of lung cancer, based on their appearance when examined under the microscope by a pathologist:

* small cell carcinoma

* squamous cell carcinoma

* adenocarcinoma.

It is important to know which type of cancer a patient has because small cell cancers respond best to chemotherapy (anti-cancer medicines) whereas the other types (often referred to collectively as non-small cell cancer) are better treated with surgery or radiotherapy (X-ray treatment). The pathologist therefore needs a small tissue sample (biopsy) to examine. This will confirm that the diagnosis of suspected cancer is definitely correct and show which type of cell is involved.

How is lung cancer treated?

Surgery can cure lung cancer, but only one in five patients are suitable for this treatment. If the tumour has not spread outside the chest and does not involve vital structures such as the liver, then surgical removal may be possible, but only if the patient does not also have severe bronchitis, heart disease or other illnesses. These additional complications put too great a strain on the patient for them to be able to stand surgery.

Small cell lung cancer is treated with chemotherapy. This is given either by an oncologist (a specialist in cancer treatment) or sometimes by a physician in chest diseases with special experience in chemotherapy. It is given in courses which means that the patient has to stay in hospital for about 48 hours approximately every three weeks.

Popular misconceptions about chemotherapy are common and there is often concern about its perceived difficulties and usefulness. However, there is no doubt that chemotherapy is effective and that it both prolongs and improves the quality of survival in small cell lung cancer. The number of courses required will depend on how well the individual patient responds.

Chemotherapy does have side effects, particularly nausea, vomiting and hair loss. However there are very good drugs to control these side effects. Hair always grows again about three months after the chemotherapy courses have finished.

There is scope for improving the results of chemotherapy and many research trials are going on. Patients who are asked for their consent to take part in a trial should not be frightened. Hundreds of patients take part in trials to detect any benefit between one treatment regime and another. This research must be done if cancer chemotherapy can continue to improve.

Non-small cell cancer may be treated with radiotherapy, chemotherapy (as part of a research trial), or with supportive care.

Radiotherapy is either 'radical' or 'palliative'. Radical is used in selected patients with localised tumours who are inoperable, and involves using high doses of radiation.

Palliative radiotherapy is widely used. It involves using lower doses of radiation - often in just one or two doses. It is very good for relieving symptoms, such as blood in the sputum (haemoptysis), bone pain, and also for helping obstruction to the airway or large veins in the chest.

What is the outlook?

About 10 per cent of patients can expect to be 'cured' - that is alive five years after diagnosis with no evidence of the cancer having returned.

However, all patients can benefit from palliative treatment which can improve the quality of survival.

The main improvement in the management of lung cancer in recent years relates to the palliative care services with an increased emphasis on symptom control and support to the family.

The course of lung cancer may be brutally short. In the UK, MacMillan Cancer Relief charity, the Hospice movement, the family doctor and their team provide invaluable support and information to patients and families affected by cancer.

Based on a text by Dr Per Grinsted, GP

DOES CANCER CAUSE SEXUAL PROBLEMS?


Sex and cancer
Reviewed by Christine Webber
, psychotherapist and lifecoach and Dr David Delvin, GP and family planning specialist

Does cancer cause sexual problems?

Yes, very frequently. You see, it is always a shock for people to be told that they have cancer or any other serious illness. Their lives are suddenly dominated by medical examinations and treatment and quite naturally all of their attention is focused on the disease.

In this frightening situation, it's not unusual for sex to take a back seat for a time. But after a while, when the patient has gathered enough strength to look forward and to take an interest in good health and a normal life once again, he or she will almost certainly rediscover an interest in sex. But it may be difficult to resume sexual relations - particularly if you are tired or in pain.

Does cancer cause problems in a relationship?

In most relationships, serious illness can result in anxiety and uncertainty. Furthermore, the patient may be afraid that sex could cause physical injuries.

Even after patients recover, they may worry that having sex will cause the illness to break out again. People may also have irrational fears that the illness may be contagious or sexually transmitted.

These kinds of thoughts and misconceptions can make a relationship come to a standstill. It's vital for couples in this situation to talk to each other - and to a doctor - to dispel any fears or uncertainties.

They may also benefit greatly from being referred to a medical expert specialising in psychosexual medicine, or from getting some counselling with a sex or relationship therapist.

Can it be dangerous to have sex when you have cancer?

Unless the cancer affects the genital area, there is usually no reason why the patient should not have sex.

It is a good idea for cancer patients to discuss with their doctor whether or not they can have sex. If possible, this question should be raised early in the illness before any potential operation or complicated medical treatment such as chemotherapy has begun.

Unfortunately, it has to be said that - even today - not all doctors are comfortable talking about this subject. Sometimes a nurse, or a counsellor, is a better person to chat to.

It is extremely important that patients are kept well informed about their illness and its immediate consequences in the short term and in the long term.

They will want to know what impact it will have on every aspect of their life - including their sex life. For instance, people need to know whether the treatment will have any effect on their sexual function or fertility.

Are the patient's sexual problems caused by factors other than cancer?

If a patient experiences difficulties with their sex life after cancer or any other serious disease, it may help if they ask themselves the following questions: 'Are their sexual problems a result of the disease itself or are they caused by other things in their relationship?'

If a person is not sure that he or she is capable of functioning sexually it might help to try achieve orgasm by masturbation. If this ‘works', then that is a sign that the basic mechanics of the sexual apparatus are functioning properly.

If sexual difficulties arise, it is essential that you ask a GP or specialist whether the problem is due to:

* the cancer

* the treatment of the cancer

* other factors such as psychological causes.

What can be done if cancer has led to a physical disability that affects the performance of the sex organs?

Remember that loss of sensation does not mean loss of feelings. If the illness has resulted in a male patient becoming impotent he should bear in mind that there are many highly effective treatments for impotence these days.

But he should also realise that he can still be loving towards a partner and help him or her have orgasms by methods other than intercourse. It is very possible for a person to have a sexual relationship even if the function of their genitals has been lost.

Any cancer patient - male or female - who has sex or relationship problems will also probably benefit from being involved in one or other of the excellent cancer patients' support groups. It is very useful to chat to other people who are going through similar problems to your own. This communication will help you feel less hopeless and less isolated.

Based on a text by Dr Erik Fangel Poulson, specialist

Last updated 12.08.2005

CERVICAL CANCER, WHEN YOU HAD SEX HABITUALY WITH MANY MAN,,,EASY GET CERVICAL CANCER


Cervical cancer
Reviewed by Dr Philip Owen, consultant obstetrician and gynaecologist

What is the cervix?

The cervix is the lower part of the womb or uterus and is commonly referred to as the 'neck of the womb'.

The cervix plays an important role in maintaining a normal pregnancy. In non-pregnant women, the cervix has no obvious function although it may be important to the enjoyment of sex in some women.

If you squat or stand with one leg on a chair and put one or two fingers into your vagina, you will be able to feel the smooth, rounded cervix at the top of your vagina.

What is cervical cancer?

Cervical cancer is the sixth most common cancer in women in the UK.

It is important to be clear about what is and what is not cervical cancer. Women should have a cervical smear test, often known as a Pap smear test, performed on a regular basis in order to detect the cell changes that come before cancer.

It takes many years for the early cell changes that can be detected on a cervical smear to become cancer and in many cases the changes can go away by themselves.

The vast majority of abnormal smear test results do not indicate that the woman has cancer. It is by diagnosing and treating these pre-cancerous changes (also called CIN) that the development of actual cancer can be prevented.

Cancer of the cervix is a life-threatening condition of which there are two types called squamous cell cancer and adenocarcinoma. Cervical smear tests aim to detect the early changes of squamous cell cancer.

If it is detected in the early stages, cervical cancer can be treated and cured with surgery or radiotherapy.

What causes cervical cancer?

There is no definite single cause in most cases. A viral infection of the cervix is present in most cases. Smoking appears to increase a woman's risk of developing cervical cancer, and there may also be a link to the numbers of sexual partners a woman has had at a young age.

Cervical cancer is commonest among the over 50s but it can affect all age groups.

One of the ways a woman can reduce her risk of developing cervical cancer is to attend regular cervical smear tests. In the UK, these are routinely performed every three years.

What are the symptoms of cervical cancer?

Pre-cancerous changes of the cervix (CIN), which can be detected with a cervical smear test, do not give any symptoms. While some actual cancers of the cervix do not give rise to symptoms, most cause the woman to experience bleeding between her periods or after sex.

How is cervical cancer diagnosed?

It can only be diagnosed through a biopsy of the cervix. This is usually performed at the time of an internal examination called a colposcopy.

How is cervical cancer treated?

If cervical cancer is diagnosed the treatment options will be discussed. The treatment will depend upon whether the cancer has spread to involve other tissues in the pelvis or if it only involves the cervix.

Most women's treatment will include a type of hysterectomy called a radical hysterectomy or Wertheim's hysterectomy. This type of operation is only carried out by specially trained gynaecologists.

Radiotherapy may also form part of the treatment and is aimed at destroying tumour cells that the gynaecologist cannot see.

The cure rate for cervical cancer depends upon whether or not it has spread beyond the cervix.


References
National Cancer Guidance Steering Group. Improving Outcomes in Gynaecological Cancers: The Research Evidence London: NHS Executive, Department of Health, 1999.

Based on a text by Dr Erik Fangel Poulsen, specialist

Last updated 01.05.2005

BREAST CANCER, DONT WORRY ITS CURE IF FOUND IN EARLY TIME


Breast cancer
Written by Mr Michael J Dixon, consultant surgeon

What is breast cancer?
The breast is a gland that consists of breast tissue supported by connective tissue (flesh) surrounded by fat.


How common is breast cancer?
Breast cancer is the most prevalent cancer among women and affects approximately one million women worldwide.
Breast cancer accounts for 30 per cent of all female cancers in the UK and approximately 1 in 9 women in the UK will get breast cancer sometime during their life.
hat are the risk factors leading to the development of breast cancer?
Age
The incidence of breast cancer increases with age and doubles every 10 years until the menopause when the rate of increase slows.

Approximately a quarter of breast cancers affect women under the age of 50, a half occur between the ages of 50 and 69 and the remaining quarter develop in women who are 70 years or older.

Geographical variation

There is quite a difference in incidence and death rate of breast cancer between different countries. The biggest difference is between Eastern and Western countries.

Recent, age-adjusted figures show that the rate of breast cancer per 100,000 women is 24.3 in Japan and 26.5 in China compared to 68.8 in England and Wales and 72.7 in Scotland and 90.7 in North America in white females.

However, studies of women from Japan who emigrate to the US show that their rates of breast cancer rise to become similar to US rates within just one or two generations, indicating that factors relating to everyday activities are more important than inherited factors in breast cancer.

Reproductive factors

Women who start menstruating early in life or who have a late menopause have an increased risk of breast cancer. Women who have natural menopause after the age of 55 are twice as likely to develop breast cancer as women who experience the menopause before the age of 45.

Age at first pregnancy

Having no children and being older at the time of the first birth both increase the lifetime incidence of breast cancer. The risk of breast cancer in women who have their first child after the age of 30 is about twice that of women having their first child before the age of 20.

The highest risk group are those who have their first child after the age of 35 and these women have an even higher risk than women who have no children. These observations indicate a ‘menstrual cycle effect’. During the monthly cycle a woman’s fluctuating hormone levels cause several changes within breast tissue, which are repeated every month.

These changes possibly encourage or amplify abnormalities in the cell repair processes within breast tissue, which can in some cases lead to breast cancer later in life.

Women who have fewer menstrual cycles before their first pregnancy, either through being older when they start menstruating or younger when they first get pregnant, run less chance of such an abnormality occurring.

Inherited risk

Up to 10 per cent of breast cancer in Western countries is due to an inherited factor. This factor can be passed on from either parent and some family members pass on the abnormal gene without developing cancer themselves.

It is not yet known how many breast cancer genes there are, but to date, two specific breast cancer genes have been identified (BRCA1 and BRCA2).

Previous breast disease

Women with certain benign changes in their breasts are at increased risk of breast cancer. These women present with a breast lump, have an operation and the breast tissue removed shows severe overgrowth of the cells lining the breast lobule.

The technical name for this type of breast condition is ‘severe atypical epithelial hyperplasia’. Although benign in itself, its occurrence in a particular woman multiplies her risk of developing breast cancer during her life by a factor of four.

Radiation

Doubling of the risk of breast cancer was observed among teenage girls exposed to radiation during the second world war.

Another study of women who received radiation to the chest as a result of repeated X-rays for tuberculosis, found that there was a risk among women who were first X-rayed between the ages of 10 and 14 years. Fortunately, as TB itself has been prevented, this risk is less relevant today.

Other studies have shown that women with Hodgkin's disease who received radiation therapy to the chest have an excess risk of breast cancer. As they are surviving to older age they are now developing not only unilateral but bilateral breast cancer.

The increase in risk depends on the dose and the age at which they received radiation. Data has also suggested that there is increased risk of breast cancer in the other breast in patients having radiation to one breast.

Lifestyle

Although there is a close correlation between the incidence of breast cancer in a country and the dietary fat intake of that country, more detailed studies have shown that there does not appear to be a particularly strong or consistent relationship between fat intake in any individual and their risk of developing breast cancer.

Weight

Being overweight is associated with a doubling of the risk of breast cancer in postmenopausal women whereas amongst premenopausal women obesity is associated with reduced breast cancer incidence.

Alcohol intake

Some studies have shown a link between the amount of alcohol people drink and the incidence of breast cancer, but this relationship is not consistent and may be influenced by dietary factors other than alcohol.

Hormones

Women who take the contraceptive pill are at a slight increased risk while they take the Pill and they remain at risk for 10 years after coming of the Pill.

The increased risk is, however, very small and cancers diagnosed in women taking the oral contraceptive Pill are less likely to have spread than those cancers diagnosed in women who have never used the oral contraceptive.

The duration of use, age at first use, dose and type of hormone within the contraceptive appears to have no significant effect on breast cancer risk.

Women who begin taking the Pill before the age of 20 appear to have a higher risk than women who begin taking oral contraceptives at an older age.

Hormone replacement therapy

Among current users of hormone replacement therapy (HRT) and those who have stopped using it one to four years previously, there is an increased risk of breast cancer.

The risk increases 1.023 times for each year of HRT use. This increased risk is very similar to the effect of a delay in the menopause by one year. The risk of breast cancer in a woman who has not used HRT increases 1.028 times for each year she is older at the menopause.

HRT using a combination of oestrogen and progestogen has been shown to be associated with a slightly higher risk of breast cancer than oestrogen-only HRT.

Cancers diagnosed in women taking HRT tend to be less advanced clinically than those diagnosed in women who have not used HRT. Current evidence suggests that HRT does not increase breast cancer mortality.

What are the symptoms of breast cancer?

* Generally, breast cancers are not painful and women do not feel unwell with them.

* Breast cancer is now commonly diagnosed by breast screening in women who have no symptoms. Approximately 6 in every 1000 women between the ages of 50 and 64 who attend for screening will be found to have breast cancer the first time they attend screening.

* A lump in the breast. In many cases, the woman herself will first suspect the disease because she notices a lump or an area of lumpiness or irregularity in her breast tissue. This may happen when she is examining her breasts or while washing or applying lotion to her breasts, or the lump may be visible.

Other signs of breast cancer include:

* a change in the skin: there is often dimpling or indentation of the skin with the formation of wrinkles. The nipple might be pulled in or there may be a discharge from the nipple.

* occasionally the nipple itself changes. A rash can affect the nipple or the nipple may weep.

* the breast may swell and become red and inflamed or the skin may change and become like the skin of an orange. In some breast cancers this is due to a blockage of the drainage of fluid from the breast.

* patients sometimes present with a lump under the arm which is a sign that the cancer has spread to the lymph glands.

How is breast cancer diagnosed?

If a woman has any breast symptoms it is very important that she consult her doctor so that the cause of these symptoms can be found. If breast cancer is found at an early stage this improves the chances of recovery. As a rule, the doctor will ask her a number of questions.

* Does the lump vary in relation to her menstrual cycle?

* What previous breast problems has she had?

* Is there any breast cancer in her family?

* How many children has she had?

Physical examination

The doctor will look at her breasts, first with her arms by her sides, then above her head and, finally, with her arms pressing on her hips.

By looking carefully at the outline of the breast in various positions, the doctor can often see changes in the outline of the breast, which will help identify the site and cause of any problems.

Next, her breasts are examined while she is lying flat with her arms folded under her head.

If, during this examination, the doctor finds a lump, he or she will concentrate on this area examining with the fingertips and measuring the lump.

After checking her breasts, the doctor usually carefully examines the lymph glands under the patient's arm pit and those in the lower part of her neck.

Should the patient need any further investigations, the breast specialist in the breast clinic will organise any tests that are necessary.

Mammograms

If the patient is over 35 and has not had a breast X-ray within the past year, the doctor may arrange for one to be performed. Breast X-rays are known as mammograms.

Mammograms are a good way of identifying abnormalities in the breast, but they don't always tell whether they are benign or malignant.

Further tests are sometimes necessary and these tests include ultrasound and fine needle aspiration cytology (FNAC).

Ultrasound scanning

X-rays do not pass easily through the breasts of young women. Ultrasound scanning, which is familiar to many women by its use to look at babies during pregnancy, can also be used in the breast to tell whether a lump is fluid or solid.

Ultrasound is not useful as a screening test. It is useful if an abnormal shadow is seen on the mammogram because ultrasound is an accurate way of judging whether any abnormality is benign and straightforward or whether it is more likely to be serious.

Needle tests (FNAC)

Inserting a needle into the lump will show whether it is full of fluid (a cyst) or solid. The needle can allow a sample of cells to be removed for examination under the microscope (a process called cytology) and this is a very accurate method of finding out whether the lump is benign or malignant.

If there is an abnormality on the mammogram, but no lump to feel, then using either the X-ray machine or the ultrasound machine, it is possible to guide the needle into the area of abnormality and to obtain enough cells or tissue to obtain a definite diagnosis. The very fine needles used for this procedure give rise to its name.

Having the lump removed

After investigation, the doctor may decide the lump is benign and that it can be left alone. Alternatively the doctor may suggest that the lump should be removed. This is called an excision biopsy and it can be performed either while the patient is awake under local anaesthesia or, more commonly, under a general anaesthetic.

Before any operation, the patient will be asked to sign a consent form agreeing to the removal of the lump. It is important for the patient to know that the doctor performing the operation will only remove the lump and will not take any more tissue away without explaining any further procedure to the patient first and being given her consent.

What are the types of breast cancer?

Breast cancer was originally described according to its appearances, so words like scirrhous (meaning woody) were used and still appear in the literature.

More recently, breast cancer has been classified according to its appearances when under the microscope.

Early pathologists classified breast cancers into 'invasive ductal' cancers and 'invasive lobular' cancers believing that invasive ductal cancers arose in ducts and invasive lobular cancers in the lobules. However, it is now clear that all invasive ductal and invasive lobular cancers arise either in the terminal duct or the lobule. As the terms invasive ductal and lobular are in such common usage and as they have different appearances under the microscope they are still used.

A more logical classification divides tumours into those of 'special' and 'no special' type. Invasive carcinoma of no special type is also commonly referred to as invasive ductal carcinoma. It is the most common type and accounts for up to 85 per cent of all breast cancers.

Special types of tumour have particular microscopic features and these include invasive lobular carcinoma, invasive tubular, cribriform, medullary and mucinous cancers, with other types being uncommon. Many of the special type cancers have a better prognosis - in other words the patient has a higher chance of survival.

When a cancer is examined under the microscope, it is usually possible to assess how aggressive it is: in other words how far and how fast it is likely to spread. The tumour may be assigned to one of three grades ranging from grade I to grade III in order of seriousness. For instance, a grade I cancer is non-aggressive and unlikely to cause harm. In contrast, grade III tumours are aggressive and likely to cause harm, but can sometimes be controlled with effective treatment.

How is breast cancer treated?

The treatment of the disease depends on the tumour type and the stage of disease - how far it has spread to involve either lymph glands or other organs in the body. There are various ways a cancer can be staged and classified.

A simple way of staging or classifying breast cancer is to divide it into three groups.

Early or operable breast cancer

This describes cancer that is confined to the breast and/or the lymph glands in the axilla (arm pit) on the same side of the body

Locally advanced breast cancer

This has not apparently spread beyond the breast and axillary lymph glands but involves the skin or the chest wall of the breast.

These cancers tend to have a worse outlook than early breast cancer and are usually best initially treated by drug therapy or radiotherapy rather than surgery. In locally advanced breast cancer the skin of the breast can either be directly involved by cancer or it is swollen or red. These changes occur because cancer cells get into the fluid channels that drain the breast (lymphatics) and block them, which causes the skin of the breast to be swollen and look like the skin of an orange (peau d'orange).

Locally advanced breast cancers were initially treated with surgery but this treatment was successful in only about 30 per cent of patients.

In the remainder, the cancer recurred in the areas immediately next to where the surgery was performed

Advanced breast cancer

This is where the cancer has spread beyond the breast and arm pit to other parts or organs of the body such as lymph glands in the neck, bone, lungs, liver and brain.

Other tumours in the breast

A rare form of tumour in the breast arises from the supporting tissue and is called a sarcoma. These types of tumour are rare and account for much less than 1 per cent of all malignant tumours within the breast. These are usually best treated by surgery.

How does breast cancer develop?

Initially, carcinoma cells are confined within the lobule and adjacent ducts. These are known as non-invasive cancers or 'carcinoma in situ'.

As with invasive disease, there are two main types - ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).

Under the microscope these look different and, clinically, these two types of non-invasive cancer behave differently and require different treatments. Certain types of DCIS develop characteristic tiny particles of calcium within them. These particles show up as tiny white dots on a mammogram.

DCIS is much more common than LCIS. DCIS accounts for over one fifth of all types of cancer detected by breast screening.

DCIS is treated by surgery which may be followed by radiotherapy and hormonal treatment. LCIS when diagnosed is usually treated by simple follow up with regular mammograms or with hormonal tablets (tamoxifen).

Only rarely is surgery used for LCIS.

DCIS is considered to be a pre-malignant breast disease. It is not early breast cancer, but if left untreated DCIS cells eventually spread into the surrounding connective tissue of the breast to form an invasive cancer. The time period in which DCIS changes into an invasive cancer appears to be over months and years rather than days or weeks.

When an invasive cancer has developed, it is at this stage that there is a risk that cancer cells can spread to nearby lymph glands, the most common lymph glands affected being in the axillary (armpit) region.

Cancer cells can also enter the blood stream through the blood vessels that supply the cancer and then move to other organs of the body where they grow and cause problems in these organs. The most common sites for breast cancer to spread to are the bones, lungs, liver and brain. Sarcomas if they spread do so mainly through the bloodstream.

Can breast cancer be prevented?

One particular medicine used to treat breast cancer, tamoxifen (eg Nolvadex D), has been shown in an American study to reduce the risk of developing breast cancer by approximately 50 per cent in women at high risk of developing the disease. Research with tamoxifen and some other breast cancer medicines is still being carried out to determine if these are suitable options for preventing breast cancer. However, tamoxifen is associated with some rare but serious side effects that may make it unsuitable as a preventive measure.

Screening, as currently practised can reduce the mortality but not the incidence of breast cancer (and then only in the age group that is screened).

Once a woman reaches the age of 50, she will be invited to take part in a breast screening programme. In the UK, this means having a mammogram every three years up to the age of 64, although the upper age limit of routine screening is currently being extended to 70 years throughout the UK.. The aim of screening by mammography is to pick up cancer while it is still small before it has a chance to spread.

There are various reasons why women are not normally screened below the age of 50:

* breast cancer is less common in younger women.

* mammography is less likely to detect breast cancer in young women because the breast tissue is denser which can make breast cancer much more difficult to detect.

* there is no evidence that breast screening below the age of 50 is cost effective.

How is breast cancer treated with surgery and radiotherapy?

Early breast cancer can be treated by a combination of local treatments to control the local disease and adjuvent treatments to kill any cells which may have spread.

Local treatments consist of surgery and radiotherapy.

Surgery

Surgery can be an excision of the tumour with surrounding normal breast tissue (breast conservation) or removal of the whole breast (mastectomy). Clinical trials comparing mastectomy and breast conservation have shown that the two produce identical results.

If the lump is relatively small it is usually possible for the surgeon to remove it along with a small amount of surrounding normal tissue. This is called lumpectomy, wide local excision or breast-conserving surgery.

With a larger lump, this breast-conserving operation may not be possible because so much of the breast tissue would have been taken away that it would badly distort the breast.

Once the lump and surrounding tissue is removed it needs to be examined under the microscope. In some women, the surrounding tissue is abnormal and a further operation is necessary.

A mastectomy (removal of the whole breast) may be necessary if:

o the cancer is too large to remove and leave a reasonable looking breast after surgery.

o there is more than one lump in the breast.

o the cancer is directly underneath the nipple.

o the patient has previously had a lumpectomy or wide excision and the tissue round the cancer is abnormal.


As well as removing the lump or breast, the surgeon will also usually remove some or all axillary lymph glands, which are found under the arm. There are about 20 of these lymph glands and they are the most common place for cancer to spread.

Knowing whether this has happened and, if so, how many glands are affected is important in both assessing the severity of the cancer and deciding on follow up treatment.

If the surgeon needs to check whether the cancer has spread to these glands, then removing either a single gland which drains the cancer or a few of these glands is all that is needed. If however the surgeon wants to find out exactly how many lymph glands are affected, then it is necessary to remove all 20 lymph nodes from the axilla.

If it has been decided to treat the patient by mastectomy, the surgeon will probably discuss with her the possibility of having her breast rebuilt at the same time. The results of breast rebuilding or reconstruction are usually more successful if this is performed straight away rather than left until many months or years later.

There is no evidence that immediate breast reconstruction makes any recurrence of the cancer more likely. If the cancer does return, reconstruction does not make it harder to detect.

Radiotherapy

Studies have shown that all patients treated by breast conserving surgery (lumpectomy or wide excision), should receive radiotherapy to the breast following surgery. This is given every day, Monday to Friday, over three to five weeks.

After mastectomy, radiotherapy is given to patients who are considered to be at risk of recurrence. Radiotherapy kills cells that are growing and has greater effects on cancer than on surrounding tissue.

After a few days of radiotherapy, the patient's skin may look red and feel a bit sore, rather like they have spent too long in the sun.

Towards the end of treatment, there may also be some blistering of the skin. The radiotherapy staff will give all the necessary advice about how to look after the treated skin.

How is breast cancer treated with medicines?

Medicines act on cancer cells, including those which have spread. We know that in some women there are small numbers of cancer cells that have spread beyond the breast but cannot be detected by scans. Medicines can kill these cells or prevent them from growing for many months and years after surgery with or without radiotherapy. This is called adjuvant treatment.

In some patients with larger but operable breast cancers, the medicines can be used before surgery to shrink the cancer. This allows some women who would initially have required a mastectomy to be treated by less extensive surgery. If the cancer has already spread at the time it is first diagnosed or a patient who is treated for early breast cancer develops a recurrence of the cancer at some other site in the body, then the only practical way of treating these two groups of patients is by medicines.

The medicines for treating breast cancer fall into two groups: hormones and chemotherapy. Whether the patient receives hormone therapy or chemotherapy will depend on the size of the tumour, type of tumour (including the grade) and whether the tumour has spread to involve the lymph glands.

Hormones

Most breast cancer is sensitive to the female hormone oestrogen. Sensitive cancer cells need oestrogen to stay alive and removal of oestrogen from the body or stopping any circulating oestrogen getting to the cancer cells is very effective at controlling or killing hormone-sensitive breast cancers. It is possible to determine whether a tumour is sensitive to hormones by performing a chemical test on the tumour.

Tumours can be classified into oestrogen sensitive and oestrogen insensitive tumours.

In premenopausal women who are still having regular menstrual periods, about half of all breast cancers are hormone sensitive. Over two thirds of tumours in postmenopausal women whose periods have stopped are oestrogen sensitive.

The most commonly used medicine against oestrogen sensitive tumours is tamoxifen (eg Nolvadex D). This medicine is an anti-oestrogen in its effect on breast cancers and works by stopping oestrogen getting to the cancer cells. It appears to be a very safe medicine but can cause side effects which can be distressing and these include flushing (similar to those women experience during the menopause), vaginal dryness and vaginal discharge.

Many women complain of weight gain on tamoxifen, but, in randomised studies, women taking tamoxifen put on a similar amount of weight to those women who were not receiving drug treatment. There is an increased incidence of eye problems and disturbance of vision. This is reversible if the medicine is stopped.

The most serious possible side effects of tamoxifen are that it can slightly increase the incidence of cancer of the lining of the womb, and slightly increase the risk of a blood clot in the leg (deep vein thrombosis). However the risks of both these side effects are very low. Tamoxifen has been widely used throughout the world and is a very safe medicine for pre and postmenopausal women. Few women have to stop the medicine because of side effects. Women who have had surgery for early breast cancer are commonly given tamoxifen following the surgery to reduce the risk of recurrence of the cancer.

The production of oestrogen in postmenopausal women requires an enzyme called aromatase. A new class of medicines for treating breast cancers blocks this aromatase enzyme. These medicines are called aromatase inhibitors and include letrozole (Femara), anastrazole (Arimidex) and exemestane (Aromasin). They are very effective in postmenopausal women with oestrogen sensitive tunours. The side effects include flushings, nausea and lack of appetite. Occasionally, women have to stop the medicine because of the constant feeling of sickness.

In premenopausal women the major source of oestrogen is the ovaries. Either removing the ovaries or using an injectable medicine called goserelin (Zoladex), which stops the ovaries from producing oestrogen are effective treatments in hormone sensitive breast cancer. The medicine which stops the ovaries working has to be injected once a month. Side effects of this type of medicine or removal of the ovaries include the rapid onset of menopausal symptoms.

Chemotherapy

Chemotherapy involves being given a combination of anti-cancer medicines, often up to three at a time. The prime target for such medicines is cancer cells that are actively growing and dividing. Unfortunately, anticancer medicines are not able to recognise cancer cells specifically and they also kill normally dividing cells such as the blood and hair cells. The art of the science behind successful cancer chemotherapy is combining medicines which are chosen to minimise the damage to blood cells while maximising damage to cancer cells.

Chemotherapy may be preferable for more advanced cancer that is not hormone responsive and for aggressive disease, particularly if the cancer has spread to other sites, such as the liver. It is sometimes administered prior to surgery in order to shrink a tumour. As outlined above, this sometimes means that the surgeon is able to perform less extensive surgery in patients whose cancers respond.

Cancer chemotherapy is usually given through an intravenous drip in the hand or arm on an outpatient basis. Treatments vary but each session usually lasts between one and two hours and is repeated every three weeks. Patients may be frightened because they have heard about very unpleasant side effects such as nausea, vomiting and hair loss. In fact, by no means everyone will experience all or even any of these problems. Some of the anti-cancer drugs that are in common use cause little or no hair thinning and anti-sickness medicine given with the chemotherapy works well.

A common complaint in people receiving chemotherapy is of weight gain. This is due to the anti-sickness pills which are taken after the chemotherapy. Once the chemotherapy is finished, providing the patient remains active, they should return to their initial weight. One of the less well-known side effects of chemotherapy is to cause premature menopause. This means that periods are likely to stop at a much earlier age if you have had this type of treatment. Bringing forward the menopause is particularly likely to occur in women in their late 30s and 40s, but even younger women can find that their periods temporarily stop during chemotherapy.

Treatment for locally advanced breast cancer

Some patients whose cancer is locally advanced because it has grown directly into the skin overlying the breast are suitable for surgery and are treated in an identical way to patients with early or operable breast cancer. The majority of patients with locally advanced breast cancer are treated with drug therapy followed by surgery and/or radiotherapy. Some patients with locally advanced breast cancer are treated by radiotherapy initially which can be followed by drug therapy and/or surgery.

Drug therapy can consist of either hormonal therapy in slower growing hormone sensitive cancers or chemotherapy in hormone sensitive or more rapidly growing cancers.

Outlook for patients with operable or early breast cancer

There are various factors which relate to survival in breast cancer.

These include:

* tumour size - the smaller the tumour the more likely a patient is to survive.

* spread to axillary lymph nodes - the single best factor which predicts a person's survival is the presence or absence of cancer cells in the lymph glands. The more lymph glands which are affected, the worse is the outcome.

* the tumour type.

* the grade (whether it is a grade I which has a good prognosis or a grade III which has a poorer prognosis).

* whether tumour cells are seen by the pathologist in lymph channels or blood vessels.

* whether the tumour is slow growing or fast growing.

* whether it expresses hormone receptors.

* the genetic abnormalities in the cancer.

Outlook for patients with locally advanced breast cancer

The outlook is worse than for patients who present with operable breast cancer. Local recurrence of the disease after treatment is a problem even in patients who have had drug treatment, surgery and radiotherapy. Control rates of disease are however much better than they used to be when surgery was the initial treatment. The outlook is better in patients who have a good response to their initial drug treatment. In approximately 10 per cent of patients who receive chemotherapy, the drug treatment is so effective than when surgery is performed, no breast cancer cells can be identified in the breast or the lymph glands.

Outlook for patients with metastatic breast cancer

Metastasis is the process of further spread of the cancer within the body, away from the site at which the cancer starts. People whose cancers have already spread have a much worse outlook than those whose disease is apparently localised. There are differences in survival, depending on the site affected.


References
1. Baum, M. The changing face of breast cancer- past, present and future perspectives. Breast Cancer Research and Treatment 2002;75:S1-S5.

2. Beral V, et al. Breast cancer and hormone replacement therapy in the Million Women Study. Lancet 2003;362:419-427.

3. British Medical Journal: collected resources on breast cancer: http://bmj.com/cgi/collection/cancer%3Abreast National Institute for Clinical Excellence. Breast cancer service guidance. http://www.nice.org.uk/cat.asp?c=36017.


Last updated 14.05.2005

YOUR MOLES BECOME BIGGER , BE CAREFUL , MAYBE THATS MELANOMA


Skin cancer (Malignant melanoma)
Reviewed by Dr Dan Rutherford, GP

What types of skin cancer are there?

There are two main types of skin cancer; malignant melanoma (cancer in moles), and the non-melanoma group (basal cell and squamous cell carcinoma).

Each year approximately 1 in every 10,000 people in the UK will develop a new case of malignant melanoma. It accounts for about 1500 deaths annually in the UK.

Sun radiation is a contributing factor in 90 per cent of all cases of skin cancer.

People of all ages can get skin cancer, but it is rarely seen in children. People who are exposed to large quantities of sun radiation can develop skin cancer as early as 20-30 years of age, but the disease is much more common in elderly people.

Symptoms and treatment depend on what type of cancer it is. The female to male ratio is 2:1, and it is most commonly seen (50 per cent) on the lower leg.

What is malignant melanoma?

Malignant melanoma is a type of skin cancer that begins in the skin's 'pigmentation system', ie the skin layer that becomes tanned in the summer.

Melanomas usually start in moles or in areas of normal-looking skin. In rare cases the tumour may begin in the eyes, the respiratory passage, the intestine, or the brain.

Malignant melanoma is a very dangerous type of cancer, and the patient's chances of survival often depend on early discovery and treatment.

What causes skin cancer?

Skin cancer is caused by exposure to sunlight, particularly the ultraviolet (UV) rays, and 80 per cent of cases are therefore preventable.

The risk of developing skin cancer is increased following episodes of sunburn, although the there may be a delay of many years before the cancer appears.

A small number of cases are caused by hereditary conditions, but they are also triggered by exposure to sun rays. Sun beds can also cause skin cancer.

What are the symptoms of skin cancer?

* The colour of the tumours vary from brown or black to blue or orange.

* The tumours are characterised by having ragged edges and uneven colours.

* Off-shots, sores, crusts, and reddening may be seen in the area surrounding the mole.

* The tumour may resemble a 'blood blister' under a nail.

* The mole may itch.

* Moles can be found anywhere on the body, but are typically located on the back, the shoulders, or the back of the legs.

What are the warning signs?

* An existing mole changes in colour or shape, or begins to bleed or ooze. Sores that heal very slowly may appear on the mole.

* Moles that have become unusually large.

* 'Blood blisters' especially under toenails, that are not the result of a blow.

* The appearance of a new irregular mole (it is quite normal for people to develop new moles from time to time until they reach their 40s. There is no need to worry unless the colour of the new mole is uneven, or its edges are ragged). If you are in any doubt, ask your GP to check.

* Any unusual sore, lump or blemish lasting more than a few weeks.

* Areas of skin that become scaly, itchy, tender or red, or areas that ooze, bleed or become crusty.

What can be done to prevent skin cancer?

* Avoid excessive exposure to the sun, especially the midday sun (from 11am to 2pm).

* Move into the shadow and have a 'siesta' instead.

* Clothing and sun hats can protect the skin from the harmful rays. It is especially important to cover the skin from 11am to 2pm.

* Children must be protected from sunburn.

* Consult your doctor if you have sores that will not heal or unusual changes in a mole.

How is skin cancer diagnosed?

Skin cancer can be difficult to recognise, so a biopsy is usually performed. The tissue is then examined under a microscope.

* Some GPs can perform the biopsy in the surgery but it is usually performed by a dermatologist or a plastic surgeon.

* The doctor will also look for signs indicating that the cancer has spread to the surrounding tissue or lymph nodes.

* Skin cancer requires hospital treatment.

Future prospects

It is important that the cancer be detected as early as possible. The patient's chances of being cured largely depend on how early the treatment is started. If the disease is not treated, it will cause death.

How is skin cancer treated?

* Surgery is the standard treatment for mole cancer. The extent of the procedure is determined by the thickness of the tumour, ie how deeply it has invaded the skin.

* It is necessary to remove not only the tumour, but also some of the normal skin around it, and the fatty tissue beneath it.

If there are signs that the cancer has spread to nearby lymph nodes, these will also be removed, if it is technically possible.

* Medical treatment is used in cases where the cancer has spread to other parts of the body, and surgery is not possible. Chemotherapy and radiotherapy may also be used. These treatments are carried out by specialists in a hospital.

Based on a text by Dr Eric Olesen

Last updated 01.08.2005

PROSTATE CANCER ?, (PAIN WHILE PASSING URINE?)


Prostate cancer
Written by Dr Russ Hargreaves, PhD, Director of Support and Information, The Prostate Cancer Charity, London UK

What is prostate cancer?

Prostate cancer is a disease that affects men from around the age of 45 years. It involves the prostate gland, which is a small gland about the size of a walnut, positioned just beneath the bladder, and is responsible for producing fluids that nourish and protect sperm (see Figure 1).

Since the urethra (the tube that carries urine from the bladder) passes through the centre of the prostate gland, any growth within the gland will cause pressure on the urethra, causing difficulties in passing urine.

The disease is the commonest male cancer in the UK. Around 20,000 men in this country are diagnosed each year. Sadly, approximately 10,000 British men die of prostate cancer every year, so it is a disease that needs to be taken very seriously. Because we do not routinely screen for prostate cancer in the UK, the disease is very often detected only when it has spread away from the prostate gland to other parts of the body.

Why or how do I get prostate cancer and how can it progress?

It is still not entirely clear why some men develop prostate cancer and others do not. However, we do know that there are both genetic and environmental factors that can influence it.

In terms of genetic factors, you have a higher risk of developing prostate cancer if your father or brother had prostate cancer, although the increased risk is relatively small.

Perhaps more important are environmental factors such as diet and lifestyle. Vegetarians are half as likely to develop cancer as meat eaters. When we look at geographical differences, people living in the Far East such as the Chinese and Japanese have an extremely low risk of developing prostate cancer compared with those who live in Western countries such as America and Britain.

Scientists are currently investigating whether certain dietary factors may help to prevent prostate cancer. Much of this work is focussing on the mineral selenium and a substance from processed tomatoes called lycopene. Several very large studies have shown that both these agents lower the risk of developing prostate cancer.

* You cannot catch prostate cancer through sex, nor can you infect your partner with prostate cancer.

* Smoking is not linked to the occurrence of prostate cancer.

* Vasectomy was once thought to predispose men to prostate cancer but this is no longer considered to be the case.

Prostate cancer generally takes a long time to progress and it can take 10 years before it is detected. However, some men have a particularly aggressive form of the disease, and the disease can grow and spread more quickly. The cancer has a great tendency to grow on the outside edge of the prostate gland and can therefore easily break away from the gland itself. Once it does this, it tends to travel almost exclusively to the bones including the hip bones, lower spine and ribs.

What are the symptoms?

If the prostate gland grows significantly for any reason, it can put pressure on the urethra, and this may cause various problems. Common symptoms include:

* frequent visits to the bathroom to pass urine (frequency)

* having to wake up regularly throughout the night to pass urine (nocturia)

* a sense of urgency in getting to the bathroom in time (urgency)

* hesitation before the urine begins to flow (hesitancy).

* pain while passing urine

* blood in the urine

* impotence (erectile dysfunction) (inability to sustain an erection)

* hip or lower back pain.

It is very important to emphasise that the presence of such symptoms does not necessarily mean you have prostate cancer. Indeed, any problem with the prostate will generally lead to some of these symptoms, which can include prostatitis - a prostate infection - or benign prostatic hyperplasia (BPH) - a non-cancerous enlargement of the prostate gland. However, if you do have any of these symptoms, please consult your doctor since the earlier they are treated the better.

Equally important to emphasise is that many men, especially those in the early stages of the disease, do not develop symptoms at all. Therefore, a lack of symptoms does not always mean that you are free from the disease, and further tests will be needed to confirm this.

How is prostate cancer diagnosed?

There are two very simple and painless tests that can help to diagnose prostate cancer. Firstly, a test will be carried out to measure levels of prostate specific antigen (PSA) in the blood. The other test that can be carried out is a digital rectal examination (DRE).

* PSA is a protein produced exclusively by the prostate gland. All men have a small amount of PSA in their bloodstream (around 4ng/ml). If this level rises, and it can reach 3000ng/ml or more in some men, your GP may wish to refer you to a specialist for further tests.

* A DRE involves the doctor placing a finger inside your back passage and feeling the prostate gland to check its size and shape and whether any lumps can be detected. Although not very pleasant, this should not hurt in any way.

Although neither test is 100 per cent accurate, taken together they can alert the doctor to any possible concerns. Your doctor may also take into account your age, since prostate cancer generally affects men over the age of 50 years, and he may also ask about any family history of prostate cancer.

What else could it be?

A raised PSA does not necessarily mean that you have prostate cancer. Almost any condition that causes the prostate gland to grow or swell will result in a raised PSA test result.

PSA also rises slightly as you get older. Similarly, a DRE can be very difficult to interpret and may require the expertise of a doctor with specialised knowledge.

What can your doctor do?

If a prostate gland feels large and smooth on a DRE, then this generally indicates BPH, which is not life threatening and can be treated in many ways. However, if it feels lumpy, then there may be cause for concern and this will require further tests.

Equally, the PSA result can be high in men with BPH or prostatitis as well as in those with prostate cancer. There tends to be a very grey area when the PSA is between 4 and 10ng/ml, and such a result could indicate various prostate conditions. However, if the PSA increases above 10ng/ml, your doctor will almost certainly want to send you for further tests.

Always take a pen and notepad (or perhaps your partner or friend) to the consultations that you have with your doctor. This will enable you to remember what has been said to you and will help you discuss your condition with others later on.

In men with suspected cancer, a referral is usually made to a specialist known as a urologist. The urologist will usually repeat some of the tests that you have already had and may then carry out a rectal ultrasound and biopsy to understand the cause of your symptoms. Here, a small probe is placed inside the back passage, which emits ultrasound waves (similar to those used to see unborn babies in the womb) that provide an image of the prostate gland and its surrounding tissue. The urologist can then insert tiny needles into the gland to take small biopsy samples.

This tissue can then be analysed under a microscope to give a much clearer understanding of the cause of the problem. You will be given antibiotics during this time to prevent any possible infections after the biopsy. You may also notice a small amount of blood in your urine or faeces. This is not usually a problem, but if it persists you must consult your doctor.

How is prostate cancer treated?

If prostate cancer has been detected in the biopsy specimens, you now have several difficult choices to make with regard to treatment. The way the disease is treated depends on many factors, including your age and the size and grade of your cancer.

The biopsy specimen is often given a score (1-10, known as a Gleason grade, with a score of two representing the least aggressive form of the disease and a score of 10 the most aggressive cancer.

Very often, the lower-grade cancers can be left alone and will not grow significantly or spread. However, higher-grade cancers (particularly those over a Gleason grade of seven) will often be treated with either surgery or radiotherapy.

Another important factor is whether the cancer is fully contained within the prostate gland or whether it has spread to other parts of the body.

Surgery

For localised cancers (those which are contained) it is possible to remove the entire gland in an operation called a radical prostatectomy. Here, the surgeon makes an incision in your lower abdomen and takes out the whole prostate gland and then re-connects your urethra to your bladder. This is a tricky operation and requires a very skilled surgeon to avoid cutting through the nerve bundles that surround the prostate gland. Because of the likelihood of some nerve damage, impotence is a common problem, and around 70 per cent of men will not be able to achieve a natural erection after the operation.

There is also a slight risk of incontinence, with around 40 per cent of men experiencing minor dribbling and approximately 2 per cent of men requiring the long-term use of incontinence pads. However, surgery is one of the best-tested treatments and is thought to be very effective, provided that the cancer is contained within the prostate gland.

Radiotherapy

This technique can also be used to treat contained cancers. It can be done in several ways. In external beam radiotherapy, radioactive beams are aimed at the prostate from outside the body. However, radiotherapy beams cannot distinguish between normal and cancerous cells, so the beams need to be focussed very carefully on the prostate gland itself.

A newer method, known as 3D conformal radiotherapy, is now used in many hospitals. This technique involves feeding the co-ordinates of the prostate (size, shape, position) into a computer, which then shapes the beams to fit the prostate to limit the damage to normal tissue.

There are fewer side effects with this treatment, with around 40 per cent of men becoming impotent and around 2 per cent of men experiencing incontinence. Because 3D conformal radiotherapy has only been available for a few years, we are not certain of its effectiveness, but studies should be completed soon to give a fuller understanding.

Brachytherapy

This is type of radiotherapy involves placing radioactive seeds inside the prostate gland itself, thereby delivering radiation directly to the cancer.

In this procedure, the doctor inserts needles into the prostate gland under anaesthesia and then passes the seeds through the needles into the gland, where they remain forever. The seeds eventually lose their radioactivity and become ineffective. Because there is no need for surgery, the procedure can generally be carried out in a day or two, and you should be able return to normal life immediately.

Around 3 in 10 men will become impotent after brachytherapy, and a small number of men will experience a burning sensation while urinating, although this normally disappears within weeks.

Brachytherapy in its current form is a relatively new technique, but new studies have monitored men for 10 years and found it to be comparable to surgery in its ability to destroy the cancer.

Watchful waiting

Because some cancers grow very slowly, it is sometimes appropriate to do very little. Known as watchful waiting, this is especially appropriate for men in their 70s whose cancer may grow so slowly that it will not alter their life expectancy.

However, it can be very difficult to be told that you have cancer and that it is not going to be treated. It is important to remember that your doctor will continually monitor the progression of your cancer through PSA tests and will act if necessary to prevent it from spreading.

Hormone therapy

If the cancer has already spread from the prostate gland by the time it has been detected, it will normally be treated with hormone therapy.

Prostate cancers require the male hormone testosterone to grow and spread. Therefore, if you deprive the cancer of testosterone, the cancer is starved. Hormone therapy does just that, and although it will not completely remove the cancer, it can place it on hold for several years and can relieve a number of symptoms including bone pain and urinary problems.

Hormone therapy can also be used in men whose cancer has spread slightly, because this treatment can kill some of the cancer and will shrink the remaining gland, making it easier to then be treated with either surgery or radiotherapy.

How do you live with prostate cancer?

Ironically, prostate cancer itself may not cause you too many problems, whereas the treatment of the disease itself may do.

Many men are diagnosed through screening tests and have no symptoms at all until they are subsequently treated. The most common problems resulting from treatment are impotence and incontinence. However, a diagnosis of cancer is enough to frighten anybody, so you may well experience some psychological effects such as depression.

In most men, impotence can now be treated very effectively with various therapies. It is very important to ask your specialist about the risk of impotence if you would like to maintain a physical relationship. Your doctor can also refer you to an impotence adviser who can help you to find the most suitable treatment for you and your partner.

Incontinence can be more difficult to manage and men often resort to wearing incontinence pads. However, there are other devices, and your doctor can refer you to an incontinence nurse, who will help you find the best solution to the problem. In extreme cases it is also possible to have a surgical operation to minimise incontinence.

Above all, there is no right or wrong way to deal with your diagnosis. If you feel like sharing your experiences with somebody, there are plenty of organisations and support groups that can provide extra information for you, your family and even your friends.

If desired, they can also put you in touch with other men with the condition. It is very important to become informed about this disease before you select a treatment. By arming yourself with knowledge of the various pros and cons of each treatment, you can make an informed choice that is right for you.


Last updated 15.09.2005

Acute leukemia ,fact and problem


Acute leukaemia
Reviewed by Dr Rachel Green, consultant haematologist

What is leukaemia?

Leukaemia, or blood cancer, is a disease of unknown cause where the bone marrow produces large numbers of abnormal cells. This means that the normal marrow is pushed into smaller and smaller areas, which results in fewer cells being produced and leads to some of the symptoms listed below.

There are many types of leukaemia and each of them is classified according to the exact cell type affected by the disease.

Chronic leukaemia is a slowly progressive form of leukaemia and tends to involve more mature cell types.

Acute leukaemia is rapidly progressive if not treated and involves more immature cells. It develops rapidly from the earliest forms of cells in the immature bone marrow cells (blasts). It requires urgent medical treatment but is generally responsive to chemotherapy.

Acute leukaemia is a rare disease that is more common in children and young people. However, their survival rate is better than in older people.

What are the symptoms of acute leukaemia?

* Sudden appearance of symptoms.

* An unnaturally pale complexion (anaemia).

* Fatigue.

* Pain in the joints. When children are affected, this is sometimes mistaken for growing pains.

* Repeated infections, such as sore throats.

* Acute leukaemia is also usually accompanied by nosebleeds and bruising easily, often without any kind of blow or fall.

If any of the above symptoms develop, it is advisable to consult a doctor. Parents are understandably afraid of leukaemia, but fortunately, the diagnosis often turns out to be something else entirely, as many other diseases have similar symptoms.

How is acute leukaemia diagnosed?

Many forms of leukaemia can be diagnosed by blood tests. Commonly, the acute leukaemia cell (blasts) can be seen circulating in the blood.

A bone marrow test will also be performed to diagnose the type of cells involved, as this can help doctors decide on the best choice of treatment.

Acute leukaemia is usually easy to diagnose.

How is acute leukaemia treated?

Most patients with acute leukaemia will be referred to specialist units for investigation and treatment.

These days, medical treatments are extremely effective and an ever-increasing number of children and young people recover completely.

Treatment is usually with chemotherapy given through the veins. In most cases, chemotherapy is given in courses over four to six months. Each course lasts four to five days. Chemotherapy kills all fast dividing cells and this includes normal body cells as well as cancer cells.

The normal bone marrow is sensitive to chemotherapy and the blood counts may drop, making the patient vulnerable to infection and bleeding. This generally means that the patient has to remain in hospital for weeks following chemotherapy. However the blood counts will recover over time. Blood transfusions are likely to be given during this vulnerable period.

Chemotherapy can lead to hair loss, nausea, vomiting and diarrhoea. Doctors will give medicine to prevent or reduce the vomiting and diarrhoea. Hair loss is not permanent and hair re-grows after three to four months.

Sometimes a bone marrow transplant will also be recommended by the doctor. This is a way of giving larger doses of treatment. It is a very aggressive form of treatment and so is only recommended for young, fit patients. The cells used for this sort of treatment may be the patient's own, donated by a brother or sister or by an unrelated donor.

The medical treatment can be unpleasant. Recognising this, specialised hospital staff are trained to give as much help and support to patients as possible.

Based on a text by Dr Per Grinsted

Last updated 01.05.2005