Despite the great advances in medicine, breast cancer remains for the most part an unpreventable disease, and is the most common cancer in women. The majority of women with breast cancer indeed are cured of their disease; nonetheless, breast cancer is only secondary to lung cancer among the causes of deaths from malignancy in American women. Recent advances, particularly early detection, have improved survival in women with breast cancer.

Breast cancers typically are detected in one or more of three ways: examination by a physician or other person, by breast self-examination, and since the late 1960’s, by mammography – X-ray examination of the breasts. Of these, only mammography has definitively been demonstrated to make an improvement in the cure rate of the disease, presumably because of earlier discovery.

Mammography

Current recommendations for “screening mammography” [performing the examination when there is nothing known to be abnormal in the breast] in women without high risk of breast cancer include a “baseline” mammogram between ages 35 and 40, and annual mammography screening starting at age 40. How long this should continue late into life is somewhat controversial; it is this surgeon’s opinion, and that of many other physicians, that annual screening should continue as long as a woman remains in generally good health. In special high-risk instances, such as when close family members have had breast cancer, the initiation of screening might well start at an earlier age.

It is most important that mammography be performed at a facility that is accredited by the American College of Radiology. Interpreting mammograms requires considerable skill, and should be done by a physician who is board certified or board eligible in radiology (the field of interpreting X-rays and other imaging studies).

Mammograms are relatively inexpensive; modest discomfort at most can be expected during the procedure. Most studies obviously are normal, but a suspicious finding on mammography does not mean breast cancer – it merely is the proper result of the screening examination, indeed the very purpose of doing the study. Of necessity, radiologists must call attention to all potentially significant abnormalities on mammography X-rays; far less than half eventually turn out to be cancer.

Mammography is not perfect. Some 8 to 12 percent of cancers simply are not detectable by X-ray. If an abnormality is found on a mammogram, the radiologist may recommend biopsy, request additional X-ray views, or recommend close follow-up, with a repeat study in perhaps three to six months. An ultrasound study may be requested to see if the lesion is a cyst (fluid filled); if so, it likely is not of concern. When biopsy is recommended, several options are available: the most common method when a breast lesion cannot be felt is to do a needle-directed biopsy, whereby the radiologist marks the lesion with a fine wire, and then subsequently a surgeon takes out the area in question. Other methods of breast biopsy include needle aspiration, and the use of X-ray guided stereotactic methods. These are discussed in the separate article on surgery for breast lumps.

Evaluation of Breast Lumps:

If a woman, or her doctor, husband, or other person finds a lump in her breast, it must be explained – either by its complete disappearance when a needle is placed within it and fluid removed or by its complete surgical removal and subsequent pathological examination (excisional biopsy). When a woman presents with a breast lump the next step often is mammography. The primary purpose of the X-ray in this instance is not the evaluation of the lesion in question, but rather to search for additional undetected lesions. IT IS A GRAVE MISTAKE TO ASSUME THAT A BREAST LUMP IS NOT CANCER BECAUSE THE MAMMOGRAM IS NORMAL.

Many surgeons and other physicians perform an aspiration as the first step in the evaluation of a breast lump, often at the initial office consultation. Using local anesthesia, a needle is placed into the lump. If it is a cyst, it likely will disappear as the fluid is aspirated into the syringe. Unless the fluid is bloody, a woman can be reassured that all is fine. Simple follow-up to be sure that the lump stays resolved is all that is needed.

If the lump proves to be solid on the initial needle aspiration, a sample of the microscopic cells suctioned into the syringe may be sent for microscopic evaluation. This fine needle aspiration cytology can be very helpful; the important thing to remember is that it is definitive only when positive for cancer. If it is negative or indeterminate, it does not mean there is no cancer, although such a negative study can be somewhat reassuring.

The only compete and definitive method of evaluating a breast lump to be sure it is not cancer, other than its disappearance when aspirated, is its complete removal and examination by a pathologist. Anything less is unacceptable, and could result in the potential opportunity to cure cancer being lost.

Common Questions:

What if a lump is found to be a cyst on mammography and/or ultrasound? Cysts are benign – is any further treatment needed? Most authorities agree that if a lump is shown to be a fluid filled cyst by ultrasound study, and it cannot be felt on examination, leaving it alone is safe. If it can be felt, it has to be treated by needle aspiration, or if that fails, by removal.

If a mammogram is consistently normal year after year, do I still need the study every year — after all, Medicare pays for screening only every two years? The reason Medicare reimburses for screening mammography only once every two years is based on financial concerns of the Medicare program, not any scientific study. No one knows the “lead time” necessary to detect cancers before they spread and are less likely to be curable. The one-year standard we have adopted for mammography is somewhat arbitrary. The average breast cancer takes at least three years to grow from a tiny cell division gone awry to the development of invasive cancer. Numerous studies have proven the one-year interval to be safe and cost effective. One has to balance the rate of growth of the cancer versus our ability to detect it, and leave some room to correct the unavoidable errors that occur in any human endeavor.

Treatment of breast cancer is beyond the scope of this short article. With early detection, before a cancer can even be felt, cure is far more likely than when the cancer is not found until it grows large enough to be felt. Further, breast conservation treatment, avoiding the disfigurement of breast removal, is much more likely to be both feasible and successful earlier rather than later, when the lump is larger and treatment options more limited.

Francis C. Evans, MD, FACS

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Cancer is a pervasive part of our society. It affects all ages and each generation has its unique experiences with this menace to our well being. Gastroesophageal cancer is a silent stalker here in the South. More specifically, it is a cancer that develops at the junction between the esophagus, the tube that connects the stomach with the mouth, greater part of their lives and its onset is slow and insidious. Recent statistics and my and the stomach itself. It often preys on patients who use alcohol and tobacco for the own personal experience suggest that this disease may be becoming more ominous and more aggressive that historical controls would indicate.

A typical patient with cancer of the esophagus seeks medical attention because of symptoms of dysphagia or difficulty swallowing and weight loss. The patient maybe unable to swallow solid food but may do OK with liquids. Other patients may find the reverse to be true. Usually the patient feels that he or she is otherwise healthy and has no unusual risk factors or recent illnesses. The duration of symptoms is usually 1 to 6 months and most patients have no history of this type of problem in their family. All are convinced that a pill from their doctor will fix whatever is wrong with them and they will be free to resume their usual activities and bad habits quickly. What are the real facts?

It is well accepted by cancer researchers that cancer of the distal esophagus and proximal stomach (GE junction tumors) are the end result of a multistage process involving an “initiation stage” and a “promotion phase.” The initiation phase begins when a carcinogen (an alkylating agent or chemical irritant) attacks the wall of the esophagus or stomach. This initial damaged area may heal on its own, or if not properly repaired, lead to changes in the underlying cell structure.

The promotion phase occurs as the injured cell structure begins to grow faster than the cells surrounding the damaged area. This early lesion is called an in situ tumor or early tumor localized to a very superficial area of tissue. The following sequence of events seems to follow: Normal tissue leads to hyperplasia or fast growth cell structure and this leads to dysplasia or abnormal cell structure. The next step is in situ or early invasive cancer followed by full blown invasive cancer and then lastly metastasis or spread to other parts of the body. Most cancers in this area historically grow from either the lining of the esophagus (squamous cell) or the lining of the stomach (adenocarcinoma). We are also beginning to see unusual variants of other cell lines all with similar clinical presentations.

Most patients with cancer of the GE junction are in their 60ties. They are usually male and usually have enjoyed tobacco and alcohol for many years. A recent review at Memorial Hospital in New York of 258 patients showed a 27 month overall survival for adenocarcinoma arising from the stomach and a 22 month survival for tumors arising in the esophagus both treated with surgery. Patients treated with radiation or chemotherapy died in 7 months. More malignant types of tumor in this same area called small cell tumors often cause death in 6 months regardless of the type of treatment. If tumors can be discovered in their early phases, the survival rate for all tumor types is much higher with possibility for cures.

On the basis of my experience and published data, if the patient has early signs and symptoms related to swallowing and weight loss problems, the following tests are needed to rule out an early cancer.
A chest x-ray
2.) A CAT scan of the chest and abdomen
3.) An endoscopy in which the surgeon looks down the esophagus with a scope at the area in question and performs a biopsy.
4.) A barium swallow in which the radiologist asks you to swallow barium dye and then takes a series of x-rays to look at the area.
5.) A bronchoscopy which is a test to look at the inside of the airways in the lung with a scope for any evidence of tumor extension into the lung.
6.) An evaluation of the strength of your heart function and breathing capacity.
7.) A bone scan to see if the tumor has spread to your bones.
Assuming that you pass all of the screening tests, then you may be a candidate for surgery and may have an increased hope for cure. Surgery itself is planned to remove all of the known tumor and then to reconnect the lower normal part of the stomach to the mid to upper portion of the remaining esophagus. The surgery sounds ghastly, but actually has worked well, and most patients are able to eat a normal diet and return to their usual activities.

Recommendations

1.) Evaluate all early symptoms of weight loss and difficulty swallowing as soon as you can see your doctor.
2.) The preoperative work-up outlined above can be used as a reference for the tests that you may need during this process.
3.) There is hope for the future with early recognition of the problem and aggressive work-up. Your doctor may ask you to see an Oncologist for recommendations and perhaps a Radiation therapist. If you are a candidate for surgery this remains the gold standard for the best hope for cure. Good luck.

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Introduction
Epidermoid or squamous cell cancer of the head and neck (SCCHN) is often a tragic and debilitating disease that is preventable in most cases. As in most cancers, early detection and treatment are the keys to curing these malignant tumors. The strong relationship between these tumors and tobacco and alcohol use is undeniable. Therefore, eliminating such habits goes a long way toward prevention of these cancers. In the last two decades, treatment has focused on ways to cure SCCHN without the functional and cosmetic consequences of radical surgery.

Epidemiology and Risk Factors
Head and neck cancers are seen more often in urban areas in industrialized nations. It is in these areas where tobacco and alcohol use, as well as air pollution, tend to be highest. Tobacco acts directly as a cancer-causing agent and also facilitates the cancerous effects of alcohol. Cigarette smoking can affect the tissues of the entire nose, throat, windpipe (trachea) and voice box (larynx). Marijuana smoke is felt to contain even more cancer-causing agents than tobacco. Chewing tobacco and snuff are most likely to affect the mouth, where they bath the tissues. SCCHN is more common in men and has some hereditary tendency. Other risk factors include chewing Betel nuts and smoking “chutta” (lit end of the cigarette in the mouth), as practiced in some parts of Asia. In China and other Southeast Asian countries one form of SCCHN that begins in the back of the nose (nasopharynx) appears to be related to dietary nitrites contained in smoked fish. This particular tumor has also been linked to the Epstein Barr Virus (EBV). Patients infected with HIV or the AIDS virus are at higher risk of developing SCCHN. In the United States, the frequency of head and neck cancers has been declining as the use of tobacco has become less common.

Presentation and Natural History
Damage to the mucous membranes of the nose and throat from tobacco and alcohol leads to abnormalities in the cells of these tissues. At first there is inflammation and a tendency for the cells to multiply and produce protective materials known as “keratin.” Early on there may be white, raised areas on the mucous membranes known as “leukoplakia.” These contain cancer in less than 1 percent of cases. However, as the tissue damage continues, the areas become red and are referred to as “erythroplasia.” Here the chance of cancerous cells being present is greater than 75 percent.

Head and neck cancer starts in the mucus membranes of the mouth, throat, nose, sinuses, esophagus, trachea, or larynx (see figure below).

Symptoms depend upon where the tumor begins. Hoarseness indicates involvement of the vocal cords. Sore throat can occur from involvement of the tonsils, tongue or other parts of the throat. Nasal blockage with bleeding or swelling of the face may indicate tumor in the nose or sinuses. Sometimes the cancer can be seen as a lump or ulcer in the mouth or nose. Occasionally, involvement of certain nerves can cause symptoms such as weakness of the face, tongue, voice, and swallowing mechanism. The cancer irritating a nerve ending deep in the throat occasionally causes ear pain in the absence of ear infection. Some tumors can grow large enough to block the upper airway, causing noisy, difficult breathing that can become life threatening.

Early cancer of the tongue
Head and neck cancers tend to spread through tiny channels called lymphatics that lead to the lymph nodes in the neck. The lymph nodes become enlarged as they then try to contain and destroy the tumor cells using cells from the immune system. This results in painless, nontender lumps in the neck that grow larger over time. The figure on the left depicts typical patterns of spread into various lymph node groups in the neck by cancers originating in specific areas of the nose and throat. Spread to the neck indicates an advanced stage of the cancer. However, aggressive treatment can still result in a cure.

Although the cancers tend to reveal themselves in the head and neck, there are occasional instances when the tumor has spread (or metasta-sized) to other organs, such as the lungs, bone, brain, and liver. This is usually a late, advanced stage of the cancer that is rarely curable.
Evaluation

Assessing someone with a suspected SCCHN involves a thorough examination of the head and neck by an otolaryngology or head and neck specialist. This involves looking at and feeling the tumor where it begins in the nose, mouth, larynx, trachea or esophagus, as well as any swelling in the neck. A suspicious area can be an ulcer or a red, raised, irregular lump in the mucous membranes. In the neck, swelling can be firm to hard, movable or stuck to the deep tissues, and two to several centimeters in size.

If the cancer is easily accessible (such as the lip or tongue) a simple biopsy can be done with local anesthesia in the office. In this case Novocain is injected into the tissue to numb it, and a small piece of the suspicious area is removed and sent for microscopic analysis by a pathologist. Any lymph node swelling can be assessed by sampling it with a fine needle, sending the aspirated tissue for pathology examination. However, no cuts or open biopsies should be performed on the lymph nodes to prevent spreading the tumor into the surrounding skin and soft tissues.

Imaging studies can be useful to show the internal extent of deep tumors and the presence of abnormal lymph nodes that may be difficult to detect. CT (computed tomography) and MRI scans give the most detailed information. More recently, PET (Positron Emission Tomography) scans employ nuclear medicine and digital technology to detect early recurrent cancer or metastases to other organs. The PET scan is particularly useful in following patients after therapy.

All patients with SCCHN should be examined under anesthesia. The “panendoscopy” involves checking the mucus membranes of the nose, mouth, throat, larynx, esophagus, trachea and lung. The purpose is not only to examine deep tumors and obtain biopsies, but also to look for second cancers. Since the tissues of the upper airway and digestive tracts are all simultaneously affected by years of tobacco and/or alcohol exposure, it is not unusual to find two or more cancers in different sites.

Treatment
“Precancers” that exist as leukoplakia or erythroplasia can be treated with Beta Carotene or Vitamin A. There is considerable evidence that these derivatives are protective in patients that may progress toward frank cancer. Beta Carotene is preferred since it is best tolerated. Removing leukoplakia or erythroplasia surgically is often necessary when there is suspicion of cancer in the tissue.

The “early” cancers of the head and neck are typically confined to a smaller area and have not spread to the lymph nodes of the neck. Usually, these tumors are treated with either radiation therapy or surgery. Surgery is preferred when there will be little or no loss of function or change in appearance. It avoids the long-term dry mouth caused by radiation’s affect on the salivary glands. Radiation is preferred when surgery will cause cosmetic or functional deformities or when surgery cannot remove lymphatic tissues that might contain cancer cells (such as in the neck). The oral dryness caused by radiation has been less of a problem in recent years because of the use of medications such as amifostene, which protect the salivary tissues. The early cancers can be cured in 75 to 95 percent of cases. “Cure” is defined as disappearance of the cancer for more than five years.

Advanced cancers are typically larger and involve the lymph nodes of the neck. Classically, both radiation and surgery have been required to control these tumors. The side effects of aggressive surgery and radiation can be devastating. Permanent loss of voice, swallowing and speech problems, shoulder pain and weakness, facial and neck deformity and scar, paralysis of cranial nerves, and loss of vision are a few of the dire consequences. In the last few years, research has uncovered ways to treat these advanced cancers with chemotherapy and radiation therapy with similar cure rates to surgery/radiation. In many cases, vital organs such as the larynx and tongue can be spared and radical operations on the neck can be avoided. The response of the cancer to chemotherapy is often an indicator of how likely the tumor can be cured. A complete disappearance of the cancer after one or two chemotherapy treatment sessions (cycles) typically bodes well for the patient. When the cancer responds poorly to two cycles of chemotherapy, it is often necessary to resort to surgery along with radiation therapy. Chemotherapy and radiation do lead to a short-term “mucositis,” a severe inflammatory reaction akin to a severe burn of the mucous membranes of the mouth and throat. Other reactions include nerve damage and temporary weakening of the immune system. Chemotherapy is often given for several days at a time for several sessions. Radiation is given daily or twice a day for five to seven weeks. Chemotherapy can be given before radiation in so-called “induction” therapy or in between shorter courses of radiation in “concomitant” therapy. Whether the advanced cancers are treated with surgery/radiation or chemotherapy/radiation, the cure rates are typically about 50 percent overall. Most relapses occur within the first year after treatment. Some patients who fail chemotherapy/radiation are candidates for surgical treatment or “salvage.”

Research into other therapies continues, as the cure rate for advanced SCCHN is still poor. It has long been felt that the key to controlling cancer lies in the immune system. Antibodies are proteins that the body produces to fight off infections and to destroy cancer cells. “Monoclonal antibodies” have been produced that direct their efforts against a specific type of cancer cell. These antibodies can be linked to radioactive substances that can then be targeted against the cancer cells. There are still many practical stumbling blocks in using this technology today as research continues.

Conclusion
Cancer of the head and neck can be a devastating disease with complicated treatment regimens and loss of vital functions, such as speech and swallowing. Our best weapon against this disease is prevention. The elimination of smoking and other tobacco use would likely prevent over 90% of these tumors. Although chemotherapy with radiation has helped to prevent the loss of vital organs in this disease, improving cure rates for advanced head and neck cancer will likely require further research into how our immune systems respond to cancer cells.

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Here in the Southeast many patients have a long history of smoking most of their lives. In at least 80% of lung cancer or bronchogenic carcinoma cases in our part of the country, a direct link can be made to smoking and tobacco use. Usually the typical patient presents to his physician with symptoms of shortness of breath, cough, morning sputum production or an occasional episode of coughing up blood. At other times, the patient may be asymptomatic and deny any significant pulmonary symptoms.

More commonly, the patient has smoked 1-2 packs per day for many years and despite the efforts of his family and doctor, has been unable to stop smoking. Other times, a routine chest x-ray shows a solitary pulmonary nodule or lump in the lung which appears to be abnormal. When a nodule is found, it presents both a diagnostic and a therapeutic dilemma as well as a chance to “cure” early lung cancer.

Most solitary lesions are between 1 and 4 cm in diameter and are well circumscribed with normal lung surrounding the lesion. There is usually no evidence of any other abnormality on the chest x-ray and the lesion itself appears round in shape. In some cases, if old x-rays can be found to compare with the current films, and if the lesion is unchanged for more than 2 years, we can say that it is most likely a benign scar or an area of healed pneumonia. Unfortunately, this is rarely the case with most patients who smoke.
The first step in the workup of a solitary lung lesion that your physician may recommend is to obtain a CAT scan of the chest and lungs and mediastinum (the area between the lungs). The CAT scan generates a scan density number of the lesion measured in Hounsfield units. The higher the number, the more often the lesion is benign. Very high numbers and very low numbers are pretty reliable, but the mid range is still in question. Therefore, in these patients, a second test called a CT directed needle biopsy of the lesion is performed.

This test works the best when the lesion is near the edge of the lung and is more risky to the patient if the lesion is close to a major artery, airway, or the heart. If the lesion is close to the edge of the lung, a needle biopsy may be the safest and most cost effective route toward the final diagnosis. This technique is not without its own complication rate and carries a 15% chance of a pneumothorax (collapsing the lung) from the test even when performed properly.
Another test often recommended by thoracic surgeons is called a fiberoptic bronchoscopy. A small tube with a light on the end is introduced down a patient’s airway and into the lung to look at the air passages for signs of tumor. The patient is sedated, but not put to sleep for the test. The test takes about 10 minutes and may provide alot of information about the internal anatomy of the lung. If the lesion can be seen, it can be biopsied, brushed with a small brush for cells, or washed with saline for cytology examination. These specimens are sent for cultures to rule out tuberculosis, fungus, bacteria and a look under the microscope to search for cancer.
Another new tool in the search for cancer is called thoracoscopy. This test has been available since 1993. A small TV camera is placed into the patient’s chest via a small incision and if the lesion is near the edge of the lung, it can be excised or wedged out with a stapling device. The nodule is then sent to the pathologist for evaluation under the microscope and a diagnosis is then made. If the lesion is benign, the work-up is complete and the patient can resume his normal activity schedule in about a week.

If the lesion is found to be tumor, then a metastatic screening process must be carried out to look for tumor in other areas of the body. Patients with neurological symptoms should have a CAT scan of the brain to look for brain METs. Patients with this finding are usually offered radiation treatments to both the lung and the brain and not surgery. Patients with bone pain undergo bone scans to look for involvement in the skeleton. A program of nonsurgical management would then be started involving both radiation and chemotherapy.
If the original CAT scan of the chest showed enlarged lymph nodes between the lungs in the area called the mediastinum, then another test called a mediastinoscopy is recommended. For this test, the patient is put to sleep and a small incision is made at the base of the neck. A tube with a light on the end is advanced down to the area which contains the lymph nodes and the lymph nodes are removed. If tumor is found, the patient may be inoperable.
Lastly, a test called pulmonary function studies or breathing studies is recommended to assess the over all capacity of the lung. It also helps the surgeon determine how much lung could safely be removed if surgery is the best option to treat the tumor. Once the work-up is completed and the patient seems to be an operative candidate, then plans are made for surgery. The surgery itself involves removal of the area of the lung which contains the tumor or the area where the nodule was originally located. The post operative recovery time is about 6 weeks, but in my experience it can be much longer depending on the age of the patient and his or her ability to stop smoking after surgery.

Recommendations:
1) If you have pulmonary symptoms get a chest x-ray.
2) If a lesion is found in your lung, have your doctor proceed down the work-up algorithm outlined above.
3) If surgery is recommended, once the diagnosis is established surgery remains the best chance for cure. Lung cancer cures are directly related to how early the tumor is removed so don’t put it off too long.

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