HEAD & NECK CANCERS

HEAD & NECK CANCERS

The term "head and neck cancer" encompasses a wide range of tumors that occur in several areas of the head and neck region, including the nasal passages, sinuses, mouth, throat, larynx (voice box), swallowing passages, salivary glands, and the thyroid gland. Skin cancers that develop on the scalp, face, or neck may also be considered head and neck cancers.

Each year, approximately 60,000 Americans are diagnosed with a head or neck cancer (not including skin cancers that occur in the region). Most of these cancers are preventable. Head and neck cancer can develop in anyone, but people who use tobacco (including cigarettes, cigars, pipes, and smokeless tobacco) or drink alcohol excessively are much more likely than others to develop the disease.

TYPES OF HEAD & NECK CANCERS

There are many different types of head and neck cancer. Several of them are described below. Most head and neck cancers are termed squamous cell carcinomas, because they begin in the flat squamous cells that form a thin outer layer on many parts of the body. When a cancer is limited to that layer of cells, it may be called a carcinoma in situ. When it has grown beyond that layer and moved into deeper tissues it may be termed an invasive squamous cell carcinoma. Cancers that arise in glandular cells, such as those in the salivary glands, are called adenocarcinomas.

• Oral cancer is cancer that arises in the mouth, or oral cavity. The oral cavity includes the lips, the gums and the area behind the wisdom teeth, the inside of the lips and cheeks, the floor and roof (hard palate) of the mouth, and the front two-thirds of the tongue.

• Laryngeal cancer begins in the larynx, an organ also known as the voice box. The larynx sits at the top of the trachea, the tract that leads to the lungs. Air passes through the larynx on the way to the lungs. The vocal cords, two bands of muscle, are found within the larynx and are used for speech. The larynx also prevents food from entering the lungs. The larynx is visible on most men's throats as the Adam's apple.

• Nasal cavity and paranasal sinus cancers are found in the tissues that line these hollow structures. The paranasal sinuses are hollow areas in the bones of the face near the nose that produce mucus. The nasal cavity is found just behind the nose and is used to pass air to the throat.

• Nasopharyngeal cancer is found in the nasopharynx, the uppermost portion of the throat (pharynx). It begins just behind the nose and extends to the oropharynx, the portion of the throat found just behind the mouth. It also includes two openings that lead to the ears. (The entire throat is called the pharynx, and is made up of the nasopharynx, the oropharynx just below that, and the hypopharynx, the lower region that meets the esophagus.)

• Oropharyngeal cancer is found in the section of the throat (oropharynx) located just beyond the mouth. The region also includes the base of the tongue, the soft palate (the soft area just beyond the roof of the mouth), and the area around the tonsils.

• Hypopharyngeal cancer is found in the hypopharynx, the uppermost portion of the esophagus (the tube through which food travels to the stomach). The hypopharynx surrounds the larynx.

• Salivary gland cancer is found in the salivary glands, the structures that produce saliva to keep the mouth from drying out and aid in the digestion of food. Salivary glands may be found under the jaw, in front of the ears, underneath the tongue, and in other areas of the upper aerodigestive passages including the nose, sinus, mouth, and throat.

• Thyroid cancer develops in the thyroid gland, a small butterfly-shaped structure that wraps around the front of windpipe in the lower part of the neck. The thyroid gland is the source of important hormones that help regulate metabolism, blood pressure, heart rate, temperature and other functions.

SYMPTOMS

Below are some of the symptoms and warning signs of head and neck cancer. Many of these symptoms can be caused by other, non-cancerous conditions as well. See your doctor if you notice any of these problems.

• a sore in the mouth that won't heal (the most common symptom) or that bleeds easily

• a red or white patch in the mouth that doesn't go away

• frequent nosebleeds, ongoing nasal congestion, or chronic sinus infections that do not respond to treatment

• persistent sore throat

• persistent hoarseness or a change in the voice

• pain in the neck, throat, or ears that won't go away

• blood in the sputum

• difficulty chewing, swallowing, or moving jaws or tongue

• numbness in the tongue or other areas

• loosening of teeth

• dentures that no longer fit

• a lump or swelling in the neck

• changes in a mole or discoloration, or a sore on the skin that is crusting, ulcerated, or fails to heal (these are also signs of skin cancer).

DIAGNOSIS

Our doctors perform any of several types of tests that can help to make a definitive diagnosis of a head and neck cancer and to determine the stage of the cancer, or how far it has progressed.

Physical Examination and History

First, the doctor or nurse will take a complete medical history, noting all symptoms and risk factors. Then you will have a thorough examination of the head and neck area, during which the doctor will feel for abnormalities and looking at the inside of your mouth and throat.

Endoscopy

The doctor may use mirrors and lights to examine hard-to-see areas and may also use a flexible, lighted tube to examine areas that are less accessible. The tube may be inserted through the nose or mouth; an anesthetic spray may be used to make the examination more comfortable. This examination is called a nasopharyngoscopy, pharyngoscopy, or laryngoscopy, depending on which area is examined. Occasionally, this type of examination will be done while the patient is under general anesthesia so a very thorough inspection can be done; this is called a panendoscopy.

Imaging Tests

The doctor may also suggest several other tests, including imaging procedures such as a CT or computed tomographic scan (a special type of x-ray), an MRI or magnetic resonance image scan (which uses magnetic waves to produce pictures), or an ultrasound exam (which uses sounds waves to produce images). At Tata Memorial Centre, doctors also use PET (positron emission tomography) scans to help diagnose head and neck cancers. Currently, we are investigating whether PET scans will improve the ability to detect the spread of cancer to lymph nodes in the neck and other areas of the body.

Other possible tests include a panorex (a special x-ray of the jaws), a barium swallow, dental x-rays, chest x-rays, and a radionuclide bone scan.

Biopsy

If a suspicious area is noted, the doctor may do a biopsy: he or she will remove a small piece of tissue with either a scalpel or a needle, and send it to a laboratory for examination under a microscope. Biopsies are often done when the patient is under general anesthesia.

TREATMENT

Many cancers of the head and neck can be cured, especially if they are found early. Treatment varies according to the type, severity, and location of the disease. It may include surgery (the primary treatment method), radiation therapy, or chemotherapy. Increasingly, Tata Memorial Centre's physicians are combining treatment modalities to maximize chances of curing the cancer.

Although cure of the cancer is the primary goal in treatment, preserving a patient's appearance and ability to function, and thus the quality of life, also are very important goals and are considered an integral part of treatment. Today, advances in surgical techniques, reconstruction, and nonsurgical treatment methods -- combined with a comprehensive team approach, which brings the expertise of numerous specialists to each patient's care -- have made it possible to attain those quality of life goals in nearly every patient receiving treatment.

Surgery

Surgery is the mainstay of treatment for most cancers of the head and neck. Loss of speech was once common after head and neck surgery, because of damage to the larynx (voice box). Continual advances in surgical techniques, however, allow more patients to preserve normal functioning. Surgeons have perfected techniques, for example, that remove only part of the larynx instead of the entire organ. Indeed, larynx-preserving surgery is possible in more than half of the cases that once would have required that organ to be completely removed. Other advances now allow doctors to spare the eye when a tumor is crowding that area.

Some patients may need a surgical examination of the lymph nodes in the neck (called a neck dissection) to see if any cancer cells have spread beyond the site of origin; today, new techniques allow surgeons to remove these lymph nodes while sparing nerves that are important for shoulder function. Complex operations for tumors at the base of the skull -- once considered a very difficult prospect -- are now routinely performed. The skull base surgery team at Tata Memorial Centre is recognized as a world leader in this specialty.

When surgery is extensive, immediate reconstruction of the area is often possible. For example, in cases where the jaw bone must be removed, a surgeon can fashion a new jaw using bone from the patient's own leg. Blood vessels are moved along with the leg bone and are attached to blood vessels in the neck, creating a blood supply for the new jaw. Tata Memorial Centre surgeons developed this pioneering technique some 15 years ago. Similarly, skin and muscle from a patient's back or abdomen can now be used to replace part of the scalp. Dental implants can be used to replace teeth.

Radiation Therapy

Radiation therapy may involve external beam treatment or brachytherapy, a technique in which tiny radioactive seeds are implanted directly in a tumor. In some cases, both approaches are used. A three-dimensional method of delivering external beam radiation, known as intensity modulated radiation therapy, or IMRT, is used at Tata Memorial Centre for very precise delivery of radiation therapy to tumors. For example, this technique allows the radiation oncologist to "mold" the dose of radiation to encompass the tumor and spare the spinal cord, an approach that was impossible not long ago. IMRT helps to avoid damage to healthy tissues (thus reducing side effects) and makes possible the use of higher, more effective doses of radiation, as well as additional radiation to the area in some cases. Radiation therapy is often given in conjunction with surgical treatment, but studies are showing that in some cases, radiation therapy -- sometimes combined with chemotherapy -- is just as effective as surgery. These new approaches can often preserve the ability to speak and swallow normally, even in patients with advanced disease.

Chemotherapy

The use of chemotherapy in head and neck cancer is also expanding, especially in cases that previously would have been considered untreatable. Chemotherapy is often used to enhance the response of cancer cells to radiation therapy, and often makes it possible to preserve organs, such as the larynx, that once would have been removed. For patients with advanced disease, too, chemotherapy is helping to increase longevity; this is especially true in patients who have cancer of the nasopharynx or other areas that are not easily treated surgically. Chemotherapy drugs used include cisplatin, fluorouracil, methotrexate, carboplatin, and paclitaxel.

Investigational Approaches to Chemotherapy

Because head and neck cancers vary widely in their response to chemotherapy, Tata Memorial Centre researchers are looking at new tools to determine whether a particular cancer will be sensitive to treatment. One such experimental tool, the histoculture drug response assay, might one day permit rapid testing of cancer cells' response to commonly used drugs before treatment.

Tata Memorial Centre's clinical research protocols in head and neck cancers -- ranging from new approaches to preventing pre-cancers from becoming malignant to new treatments for advanced and recurrent cancers -- are sometimes offered to eligible patients through the clinical trial process. For up-to-date details about current clinical trials at Tata Memorial Centre, please visit our clinical trial database.

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LEUKEMIAS

LEUKEMIAS

Leukemia is cancer that originates in the bone marrow, the soft, spongy inner portion of certain bones, and in which the malignant cells are white blood cells (leukocytes).

Leukemia develops when a leukocyte undergoes a transformation into a malignant cell -- one capable of uncontrolled growth. Leukemia cells begin to multiply in the marrow, and as they do so they crowd out the normal blood cells -- those that carry oxygen to the body's tissues, fight infections, and help wounds heal by clotting the blood. Leukemia can also spread from the marrow to other parts of the body, including the lymph nodes, brain, liver, and spleen.

Leukemia is ten times more common among adults than among children. Leukemias are evenly split between the acute and chronic forms, but among children one form -- acute lymphocytic leukemia -- accounts for about two-thirds of cases. Acute myeloid leukemia and chronic lymphocytic leukemia are the most common types in adults.

Blood cell development begins in the marrow with the formation of stem cells. These primitive cells are capable of developing into any kind of blood cell. The first step in this evolution, or differentiation, is into one of two slightly more mature types of stem cells: lymphocytic progenitor cells and myeloid progenitor cells. These cells then undergo further specialization. Lymphocytic stem cells mature into either T cells, B cells, or natural killer cells. Myeloid stem cells mature into erythrocytes (red blood cells); platelets (which clot the blood); monocytes (a type of white blood cell); or granulocytes (a group of white blood cells that includes neutrophils, basophils, and eosinophils). Each of these types of cell has a very specific job in the functioning of the body.

A malignant transformation can happen at any stage of blood cell development. The leukemia cells that result carry many characteristics of the cell from which they began. Most leukemias fall into one of two general groups: myeloid leukemia and lymphocytic leukemia. Physicians also classify leukemias according to whether they are acute or chronic. In acute leukemias, the malignant cells, or blasts, are immature cells that are incapable of performing their immune system functions. The onset of acute leukemias is rapid, and, in most cases, fatal unless the disease is treated quickly. Chronic leukemias develop in more mature cells, which can perform some of their duties but not well. These abnormal cells also increase at a slower rate, so the disease develops more slowly than in acute leukemia, and in many cases is more difficult to cure.

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LIVER CANCER

LIVER CANCER

Malignant, or cancerous, liver tumors fall into two types: primary or metastatic. Primary tumors originate in the liver itself. Hepatocellular carcinoma is the most common type of primary liver cancer.

Metastatic, or secondary, liver tumors have spread to the liver from a cancer elsewhere in the body. Because one of the liver's main functions is to filter blood, cancer cells from other parts of the body may become lodged in the liver and become tumors. The most common type of metastatic liver tumors are those caused by colon cancer that has spread to the liver.

Primary liver cancer, or hepatocellular carcinoma, is the most common type of cancer originating in the liver itself. (Most tumors in the liver do not originate there; they start elsewhere in the body and spread, or metastasize, to the liver.) In the United States, primary liver cancer is relatively rare -- it accounts for less than one percent of all cancers. But worldwide, hepatocellular carcinoma is the most common solid organ tumor. This is believed to be due to widespread viral hepatitis infection, a known risk factor for primary liver cancer.

Most primary liver cancers originate in the liver's parenchymal cells -- the cells that perform most of the organ's blood-filtering functions. Other rarer forms of primary liver cancer include peripheral cholangiocarcinoma (tumors in the sections of the bile ducts that are within the liver), sarcomas and angiosarcomas (cancer in the connective tissue of the liver), hemangioendotheliomas (tumors that arise in the blood vessels of the liver), and hepatoblastomas (a highly curable form of liver cancer most often found in children).

Hepatocellular carcinoma most commonly occurs in people whose livers have been damaged. This damage may be caused by alcohol abuse, by chronic infection with the hepatitis B or hepatitis C virus, from food contaminants called aflatoxins (though this is rare in the United States), or from metabolic diseases. Cancer can spread from the liver to other areas in the body through the blood or the lymph system, most often to the lungs, bones, and abdomen.

Several benign, or non-cancerous, tumors can occur in the liver. The most common form of benign tumor is called a hemangioma. Hemangiomas can occur anywhere in the body but occur most frequently in the skin and subcutaneous tissues (tissues beneath the skin). In nearly all cases, hemangiomas of the liver are harmless. In only rare instances do they cause pain or other problems. Once checked and deemed harmless, they can be left alone.

RISK FACTORS

Hepatocellular cancer is one of the most common cancers in the world. As hepatitis B virus and hepatitis C are known risk factors for liver cancer, areas with higher rates of these infectious diseases -- including some areas of Africa, China, and Southeast Asia -- have higher rates of liver cancer. These viral infections are less prevalent in the United States, although the incidence of hepatitis C infection is growing.

Viral hepatitis is often a silent disease. The hepatitis virus can be present in the body for years and cause no pain or symptoms. As many as four million Americans may carry the hepatitis C virus, and most may not be aware that they are infected. Viral hepatitis is contracted through contact with infected blood or body fluids. In many cases, people became infected through blood transfusions administered before 1992 (before blood was first routinely screened for the disease). A small number of cases are still associated with recent blood transfusions. Intravenous drug users may become infected through contact with unsterilized needles. These infections are considered so serious that the U.S. Centers for Disease Control and Prevention issued guidelines in October 1998 requiring hospitals to track down and notify anyone who may have received infected blood prior to 1992.

Early in the infection hepatitis B can be treated with a combination of the anti-viral drugs alpha-interferon and ribavirin. In some cases the virus can be eradicated from the bloodstream and eliminated from the body. For this reason, doctors recommend that people at a high risk for developing the disease be screened. If the infection progresses, it can lead to chronic liver disease, or cirrhosis, a progressive disease of the liver, and, eventually, liver cancer. There is also a vaccine for hepatitis B. Doctors recommend that children, and those at high risk for developing the disease be vaccinated.

The risk of primary liver cancer is greater for those whose livers have been damaged by excessive alcohol consumption. Approximately 15 percent of alcoholics will develop cirrhosis of the liver. Cirrhosis also makes the surgical treatment of primary liver cancer more difficult.

SYMPTOMS

Many patients with primary liver cancer have no symptoms. In some instances, jaundice, malaise, or a general feeling of poor health, loss of appetite, weight loss, fever, fatigue, bloating, itching, swelling of the legs, or weakness may be present. Abdominal pain or discomfort may also occur.

DIAGNOSIS

Diagnosis of primary liver cancer is generally made using blood tests, diagnostic imaging, surgical biopsy or laparoscopy, or a combination of the above. The alpha-fetoprotein blood test and ultrasound imaging of the liver are also used to screen high-risk populations (including those with hepatitis B and hepatitis C infections) for the disease. Since the risk of liver cancer is relatively low for healthy individuals, these tests are not used to screen the general population.

The alpha-fetoprotein (AFP) blood test measures the level in the blood of a certain protein produced by the liver. Elevated levels of AFP can be an indication of hepatocellular carcinoma, the most common type of primary liver cancer. If liver cancer is suspected, other blood tests are done to measure liver function. These tests can help doctors determine the condition of the liver. Since successful treatment for liver cancer involves removing a substantial part of the normal liver tissue in addition to the cancer, other treatments might be used in people with blood tests that indicate a high degree of liver disease.

As non-invasive diagnostic imaging techniques have become more sophisticated, they can be used to gather important information about a newly diagnosed tumor -- including its exact size, and density. These techniques can also be used to gauge how well a tumor will respond to treatment.

In some cases, diagnosis is performed invasively, by removing a small amount of tissue for a biopsy, or by laparoscopy (insertion of a small tube with an attached camera into the abdomen to survey the cancer site). Laparoscopy can also be used to remove a sample of tissue for biopsy.

Noninvasive Diagnostic Imaging Techniques

• CT (computed tomography) scanning -- is useful for determining the extent of tumor growth within the gallbladder or bile duct. It can also be used to tell whether tumor cells have spread into the lymph nodes or other nearby parts of the body.
• MRI (magnetic resonance imaging) -- can be used to determine if a tumor can be surgically removed. It shows the extent of tumor growth within the gallbladder or bile duct and reveals whether the tumor has invaded any blood vessels
• Magnetic resonance cholangiopancreotography (MRCP) -- gives a detailed examination of the bile ducts. It is useful for determining the stage of a tumor in the bile duct.
• Ultrasound -- useful for detecting the location and number of tumors as well as tumor involvement with blood vessels (tumors situated close to blood vessels may be more difficult to remove). It can also be used to distinguish a cancerous mass from a benign tumor.

Invasive Diagnostic Techniques

Biopsy -- a small amount of tissue is removed from a specific area of the body so it can be examined more closely.

• Endoscopy -- the interior lining of a body cavity, such as the esophagus, stomach, bile duct, or colon, is examined using a device called an endoscope
• Laparoscopy -- allows for the examination of the abdominal cavity and its contents. A tube with an attached camera (called a laparascope) is passed through an incision made in the abdominal wall.
• Cholangiography -- a needle is inserted into the bile ducts within the liver. The ducts are injected with dye so they can be seen more clearly.

TREATMENT

For treatment purposes, primary liver tumors are classified in four ways. Localized and resectable tumors are found in one place and can be removed. Localized and unresectable tumors are found in one area but cannot be totally removed safely. In advanced cases, cancer has spread throughout the liver and/or to other parts of the body. In recurrent cases, the cancer has returned to the liver or another part of the body after initial treatment.

Surgery

Most primary liver cancers are best treated by surgery to remove the diseased portion of the liver. Until the early 1980s, surgery to remove primary liver tumors was rarely done. But now highly complex liver operations are performed with great frequency, success, and safety at Tata Memorial Centre. Our researchers have recently shown that hepatobiliary surgery can also be successfully performed in elderly patients. These patients can have outcomes comparable to those of younger patients, so chronological age alone should not be the determining factor when deciding upon surgery in patients over the age of 70.

Operating on the liver can be difficult for several reasons. Many of the major blood vessels to and from the heart pass behind or through the liver, so in essence, the liver is "attached" to the heart. Also, the anatomy of the liver is not always obvious from the surface. The organ is large, dense, and delicate, and covered in part by the rib cage. It bleeds profusely when injured and it tears easily. Since hepatocellular cancer is relatively rare in the United States, many surgeons may not be experienced in performing liver resections. Our surgeons perform the highest number of liver resections of any cancer center in the country -- 200 to 300 per year.

The liver has the capacity to regenerate: Up to 80 percent of the organ can be surgically removed and within several weeks, the liver will have entirely regenerated itself. If one lobe--along with its associated blood vessels--is surgically removed, the remaining lobe will compensate for the loss. A new technique which stimulates regeneration before surgery is also being evaluated here. The technique is called pre-operative portal vein embolization. If doctors feel the portion of the liver remaining after resection would be too small to allow for a good outcome, they can shift the blood supply to the normal portion of the liver before the resection is done. That normal area grows larger, and when it reaches sufficient size, the resection can be performed.

When the liver is burdened with another disease aside from the cancer, surgery is complicated and sometimes impossible. A disease such as cirrhosis dramatically weakens the liver and often leaves it permanently damaged, with limited regenerative capacity. A patient with a liver hampered by both cirrhosis and a tumor is more likely to be treated with a method other than surgery. Some of these treatments are listed below.

Ablative Therapies

Ablation uses a chemical agent or energy to destroy a tumor. Ablative procedures can be performed both percutaneously (through the skin without an incision) or during surgery. Procedures which can be performed percutaneously include cryosurgery (freezing and killing the tumor cells), radiofrequency (RF) ablation, alcohol ablation, and embolization. These therapies can be very effective but are usually intended to control cancer rather than cure it.

Ablative therapies can be used alone or in combination with surgical removal of a tumor. For example, a patient with hepatocellular cancer who is not a candidate for surgery may first be treated with embolization to shrink the tumor so that it is small enough to make another form of ablative therapy or surgery possible.

In cryosurgery, a needle is introduced into the middle of a tumor to freeze it. Residual tumor cells can be left behind, making this method less effective than surgery. It can also be difficult to keep the tumor at temperatures low enough to completely freeze it, since tumors are often near large blood vessels. Nevertheless, cryosurgery can be a very effective way to control liver tumors.

Radiofrequency ablation is the opposite of cryosurgery. Rather than freezing the tumor, physicians use radio waves to heat it up to such a high temperature that the tumor is destroyed. RF ablation is effective, but can only be used for smaller tumors. This therapy is not curative; it is intended to control tumor growth.

Alcohol ablation or PEIT (percutaneous ethanol injection treatment) is a means of administering toxins directly to a tumor. It is quite effective for small tumors of less than 5 cm. This treatment is usually selected for patients who are not candidates for surgery.

Radiation Therapy

Radiation therapy is used in selected cases to help control tumors. Radiation oncologists here use new techniques to focus the radiation beam on the tumor and spare the normal liver from injury.

Embolization

Embolization is a procedure that cuts off the blood supply to the tumor. Physicians pack a branch of the hepatic artery -- the main artery that carries blood to the liver -- with tiny plastic particles, cutting off most of the blood flow and depriving the tumor of life-giving oxygen.

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LUNG CANCER

LUNG CANCER

More than 90,000 men and 79,000 women are diagnosed each year with cancer of the lungs and bronchi (the air tubes leading to the lungs). Among men, the incidence of lung cancer has been declining, but it continues to increase among women. The number of lung cancer deaths among women surpasses those from breast cancer.

Recent studies indicate that female smokers may be more likely to develop lung cancer than male smokers.

TYPES OF CANCERS

There are two major types of primary lung cancer: non-small cell and small cell. Each affects different types of cells in the lung and grow and spread in different ways, so doctors treat them differently. A diagnosis will include not only the type of lung cancer but the stage, which describes the extent and spread of the disease at diagnosis.

• Non-Small Cell Lung Cancer

Non-small cell lung cancer, the most common type of lung cancer, is usually associated with a history of smoking. The three main types of non-small cell lung cancer are named for the type of cell found in the tumor: squamous cell carcinoma (also called epidermoid carcinoma); adenocarcinoma; and large cell carcinoma. Non-small cell lung cancer is described using four stages: in stage I, the cancer is confined to the lung; in stages II and III, the cancer is confined to the chest; and in stage IV, the cancer has spread from the chest.

• Small Cell Lung Cancer

Small cell lung cancer (sometimes called oat cell lung cancer) accounts for approximately 20 percent of all lung cancer cases and is also associated with a history of smoking. The extent of the disease is described using a two-stage system. A case can either be limited, meaning the cancer is confined to a portion of the chest where it originated, or extensive, meaning the cancer has spread throughout or from the chest.

Mesothelioma, a rare cancer of the chest and abdominal lining, primarily affects persons who have had occupational exposure to asbestos particles.

Tumors found in the lungs sometimes originate from cancers elsewhere in the body. These tumors are called lung metastases.

RISK & PREVENTION

Smoking tobacco in any form is the major risk factor for lung cancer. Nonsmokers who breathe the smoke of others, often called secondhand smoke, are also at increased risk for lung cancer. Stopping exposure to tobacco smoke at any age lowers the risk of lung cancer.

Risk factors for lung cancer besides smoking include the following:

• Radon

An odourless radioactive gas produced naturally in rocks and soil, radon is found in homes and mines in some areas. Exposure to high indoor radon levels can cause damage to the lungs that may lead to cancer.

• Asbestos

If inhaled, asbestos particles can cause lung damage that may lead to lung cancer and mesothelioma (a rare cancer of the chest and abdominal lining).

Smoking Cessation

Not everyone who gets lung cancer has a history of smoking. If you do smoke, however, you can reduce your risk for lung cancer -- and the risk of those around you -- by stopping now.

DIAGNOSIS

Lung cancer is difficult to detect early because symptoms usually do not appear until the disease is advanced. Symptoms depend on the location of the tumor and can include persistent cough, hoarseness or wheezing, shortness of breath, sputum streaked with blood, recurring bronchitis or pneumonia, weight loss and loss of appetite, and chest pain.

Physicians use several techniques to diagnose lung cancer, including the following:

Imaging Tests

Chest x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) help locate abnormal areas in the lung.

Low-Dose Helical CT

A technique called low-dose helical (or spiral) CT may offer a novel approach for diagnosing lung cancer by exposing the patient to less radiation than a conventional chest CT scan while allowing the doctor to see areas of the chest normally obscured in a standard x-ray.

Bronchoscopy & Biopsies

A sputum sample can be analyzed for the presence of cancerous cells. Doctors may perform a bronchoscopy, which allows them to examine the bronchial passages using an instrument called a bronchoscope. This is a small tube that is inserted through the nose or mouth, down the throat and into the bronchi. During the procedure physicians may remove some tissue for analysis.

A modified form of bronchoscopy called autofluorescence bronchoscopy, which can detect early invasive cancers not seen with standard x-rays or white-light bronchoscopy, is being used to detect very early lung cancer.

To examine areas of the lungs that are not accessible during a bronchoscopy, physicians may perform a needle biopsy ("fine needle aspiration" or FNA) to remove a small sample of tissue for analysis.

TREATMENT

Depending on the type and stage of the disease, lung cancer can be treated with surgery, chemotherapy, radiation therapy, or a combination of these treatments.

Surgery

For non-small cell lung cancers that have not spread beyond the lung, surgery is most often used. Over the past several years, surgical techniques for treating lung cancer have improved greatly.

There are three surgical procedures commonly used to treat lung cancer:

wedge resection, or segmentectomy (in which a small section of the lung is removed)

lobectomy (in which an entire section is removed)

pneumonectomy (which involves the removal of an entire lung)

Minimally Invasive Surgery

Where appropriate, we offer minimally invasive surgical procedures, including video-assisted thoracic surgery (VATS), or thoracoscopy. VATS allows the surgeon to operate with roboting assistance by inserting an illuminated tube through a small incision into the lung through the ribs. Because the incisions are much smaller than with an open operation, post-operative healing time and pain are reduced.

Chemotherapy

For patients whose tumors are somewhat more advanced, a program of chemotherapy before surgery increases the cure rate. In some cases, the cancer is completely eliminated with chemotherapy before the patient has even had surgery.

Even if the surgeon removes the entire tumor that can be seen, adjuvant chemotherapy may be offered to kill cancer cells that may still be present in nearby tissues or elsewhere in the body. For small cell lung cancer in particular, chemotherapy, often combined with radiation therapy, is now the most common treatment.

Radiation Therapy

When surgery is not the best option, our radiation therapy system permits the delivery of the highest possible radiation dose targeted precisely to the tumor. This method spares normal tissues and lessens damage to other organs in the chest. Radiation therapy is also sometimes used to relieve pain and bleeding and alleviate problems with swallowing.

Both 3-D conformal radiation therapy and intensity modulated radiation therapy (IMRT) allow doctors to change the shape and intensity of radiation beams so they are focused more effectively on cancer cells and away from the surrounding tissue and organs.

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SKIN CANCER

Sunlight and Skin Cancer

Ultraviolet (UV) radiation is the single most important cause of skin cancer, especially when the overexposure resulted in sunburn and blistering. Other, less common causes of skin cancer include repeated exposure to x-rays and exposure to coal tar, arsenic, and other industrial compounds.

Sunlight provides much that is beneficial and even necessary to life and good health. Tanning and burning, however, are not among those benefits -- there is no such thing as a "healthy tan."

Over the past decade, researchers have discovered that the tanning response begins only after DNA in skin cells has been damaged by exposure to sunlight. Although the exact wavelengths and timing of the solar radiation associated with different types of skin cancer are under investigation, the basic preventive lesson remains the same: protect your skin from the sun.

Fortunately there are ways to prevent most non-melanoma skin cancers and to detect them early when they do arise. When treated early, the vast majority of these cancers are curable.

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