Cancer

It is essential for the body to produce new cells for growth and to replace cells that have become damaged, diseased or that are worn out and dying write Tortora and Grabowski(1993). They also explain how somatic (body) cell division is a process by which cells reproduce themselves whereby a single parent cell produces two identical daughter cells.

Cell Cycle Kumar(2007 p27)

I summarise Kumar’s(2007) description of the cell cycle – From the resting phase (G0), the genetic material is duplicated by DNA replication(G1,S) and each chromosome becomes two identical units or chromatids. These diploid or double chromosomes eventually separate and migrate to each end of the cell(G2) before splitting  into two(M).  There are various checkpoints (also called restriction points), along the way to make sure that the process has worked correctly. Certain genes e.g. Rb and p53 check for mistakes and halt the cycle for repairs if something goes wrong.  Any cell that has an error in its DNA which is unable to be repaired may undergo apoptosis or cell death.

Waugh and Wilson(2006) explain that DNA can suffer from mutations because of a variety of genetic (abnormal BRCA1 or BRCA2 genes) and environmental agents including chemicals(cigarette smoke and asbestos), radiation(x-rays and ultraviolet light ), dietary factors (alcohol, red meat) and viruses(Hepatitis B and Human papillomavirus) that have been identified as carcinogenic or cancer causing. Few mutations will lead to cancer as most will be halted by the checkpoints in the cell cycle e.g. G1 checkpoint Rb and p53 and then either die or be cleaned up by the leukocytes as part of the immune response. Obviously the healthier the immune system, the more effective it will be in destroying cancer cells and so cancer is more likely to be prevalent in people with compromised immune systems. Even with a healthy immune system cancer can still occur if there is a higher than normal exposure to carcinogens.

Kumar and Clark(2007) conclude that cancer is essentially a disease of mitosis. The checkpoints in the cell replication (Diagram page 1) which regulate mitosis are ignored or overridden by the cancer cell. One route towards cancer is that all the above carcinogenic factors can cause proto-oncogenes which are a normal part of the cell structure to mutate and become oncogenes and thus cause normal cells to become cancerous. Cancer is not however a result of a single mutation but something that happens oover time leading to accumulated mutations to a cell’s DNA, (the Knudson hypothesis). However most cancers have inactivating mutations in one or more proteins that normally function to restrict progression through the G1 stage of the cell cycle (e.g. Rb and p16). As Kumar and Clark(2007) point out ‘The genes most commonly affected can be characterised as those controlling cell cycle check points, DNA repair and DNA damage recognition, apoptosis, differentiation and growth signalling.’

Once mutated, Waugh and Wilson(2006) describe how a tumour or neoplasm (meaning new growth) grows faster than normal in an uncontrolled manner. Tumours can be benign or malignant although it is not always possible to make a clear distinction between them.

Waugh and Wilson(2006) (p51) have a table which shows differences between benign and malignant tumours.

 

Slow Growth Rapid Growth

 

Cells well differentiated

(Resemble tissue of origin)

Cells poorly differentiated

(may not resemble tissue of origin)

 

Usually encapsulated Not encapsulated

 

No distant spread Spreads (metastasises)
(Metastases) -by local infiltration
  -via lymph
  -via blood

-via body cavities

 

Recurrence is rare Recurrence is common

 

B Signs and symptoms

Ana had been feeling very much ‘under the weather’ for about three months. She had become increasingly tired and very lethargic. Her energy levels were low as she was finding it hard to play with her children. The main sign was that she had discovered a fixed, non-tender lump in her breast sized approximately 1.5cm across at its widest, but it was not regular in diameter. There was no pain, but her breast feels quite uncomfortable. Red Flag for cancer 1.2

Any person reporting with an unexplained lump should have a non-urgent referral to a Doctor and seen within a week as this is a warning feature that something needs further investigation. Red Flags for Breast Cancer 36.7. One in ten lumps is cancerous. It may be quite benign however if it is one which is hard, irregular, fixed and painless there is a higher chance of it being cancerous, although not all lumps with these characteristics are cancerous, nor do all cancerous lumps fit this description. Red Flag for cancer 1.2.

C1 Tests for cancer

Diagram from Longmore et al (2010) p605 Breast lump-triple assessment.

Mammogram

Macmillan Cancer Support1 (2011) describes that mammograms are usually only done in women over 40, because breast tissue is denser in younger women and so it is harder to get a good picture and see any changes. A mammogram is a low-dose x-ray of the breast. The breast is flattened and compressed with a flat, clear, plastic plate to keep the breast still to get a clear picture. The procedure can be uncomfortable and slightly painful. In screening, two mammograms are taken of each breast from different angles. Diagnostic mammograms take more pictures than screening mammograms do and the emphasis may be different in that they focus on getting more information about a specific area (or areas) of concern — usually due to a suspicious screening mammogram or a suspicious lump. Some breast units now use digital mammography. The image is taken electronically and then stored on a computer in digital form

Breast ultrasound

Macmillan Cancer Support1 (2011) explains how a breast ultrasound uses sound waves to build up a picture of the tissues inside the breast. It can show if a lump is solid (made of cells) or is a fluid-filled cyst. A breast ultrasound can also show all areas of the breast, including the area closest to the chest wall, which is hard to study with a mammogram. An ultrasound is more useful than a mammogram in women under 40 and it is often used to check abnormal results from a mammogram. Ultrasound can also be done on the lymph nodes of the armpit to check if any of them are swollen or abnormal.

Biopsy

Macmillan Cancer Support1 (2011) explain that biopsy is where a small tissue sample is surgically removed and examined under a microscope for the presence of cancer cells. Some biopsies can be done on an outpatient basis with only local anaesthesia. There are several different type of biopsy:

Fine needle aspiration

A quick and simple procedure – a little like a blood test. The doctor uses a very fine needle to withdraw some cells from the lump which will then be examined in a laboratory.

Core (needle) biopsy

This procedure is carried out under local anaesthetic using a larger needle than above. A small lump of tissue is removed for analysis.

Vacuum-assisted biopsy (VAB)

Under local anaesthetic a probe is inserted and a vacuum gently draws, cuts and collects a piece of breast tissue.

C2TNM staging system

American Joint Committee on Cancer (2011) gives comprehensive details about how the TNM staging system was developed and is maintained by them (AJCC) and the International Union Against Cancer (UICC). It is a widely used tool for doctors to rank different types of cancer based on certain standard criteria.

The TNM Staging System is based on 3 categories:

  1. The size of the original (primary) tumour
  1. The extent of spread to the lymph nodes
  1. If it has spread to another part of the body – the presence of metastasis

There are various subdivisions within each category:

TX Primary tumour cannot be evaluated
T0 No evidence of primary tumour
Tis Carcinoma in situ (early cancer that has not spread to neighbouring tissue)
T1–T4 Size and/or extent of the primary tumour
NX Regional lymph nodes cannot be evaluated
NO No regional lymph node involvement (no cancer found in the lymph nodes)
N1-N3 Involvement of regional lymph nodes (number and/or extent of spread)
MO No distant metastasis (cancer has not spread to other parts of the body)
M1 Distant metastasis (cancer has spread to distant parts of the body)

Table combined from American Joint Committee on Cancer (2011)

Once the individual T,N,M stages have been categorised they are then combined into a stage groupings which have similar outcomes and can be treated with similar treatment. Stagings are denoted with Roman numerals followed by A,B or C with Stage I being the least developed and Stage IV the most. There is also a stage 0 which is non-invasive cancer. Obviously the lower the staging, the better the prognosis.

D table – pro cons conventional treatment for breast cancer

Table compiled from Kumar P and Clark M L (2009), Cancerquest (2011), Macmillan Cancer Support2  (2011), Macmillan Cancer Support3  (2011), Macmillan Cancer Support4  (2011)

Treatment Advantages Disadvantages
Mastectomy Often no need of Radiotherapy, which has short and possible long-term side effects, but may be necessary for some patients.

Some women feel less anxious about the cancer coming back because the entire breast has been removed.

 

Losing the breast can be extremely distressing.

It will permanently change the patient’s appearance.

It may affect the patient’s confidence, sex life and relationships.

Lumpectomy In early breast cancer, it’s as effective as a mastectomy.

The patient keeps her breast. Only the breast lump, or the area of abnormality seen on the mammogram and a small margin of normal breast tissue around it are removed.

The lumpectomy is a very simple surgery, which can usually be done as an outpatient under local anaesthetic.

This option is only effective for very carefully selected patients with very early, small DCIS lesions with very easily interpreted mammograms.

The patient will need three weeks of radiotherapy after surgery, but even with a mastectomy there may still be a need for radiotherapy.

There may be a worry of the possibility of recurrence – of cancer coming back in the breast.

Radiotherapy It can substantially lower the chances of recurrence in breast cancers when used in conjunction with other cancer treatments Radiotherapy has short-term side effects, such as skin soreness and tiredness, and some women may experience long-term side effects.

Affects both cancer and non-cancerous cells

 

Chemotherapy Very effective at treating breast cancer Can affect cancer and non-cancerous cells

Possibility of early menopause and infertility

Decrease in blood cell counts

Nausea, vomiting, abdominal pain

Myelosuppression (Decrease in bone marrow activity)

Decreased appetite

Hair loss (reversible)

 

Hormonal Therapy -Anti-Oestrogen (such as Tamoxifen and Faslodex) Well tolerated by the body.

Reduces the chance of breast cancer coming back and to protect the other breast.

Can also be used before surgery to shrink a large cancer to avoid the need for a mastectomy|.

 

They only work for women who have oestrogen-receptor positive cancers|.

 

In premenopausal women, some hormonal treatments bring on a temporary or permanent menopause.

Aromatase inhibitors only work in women who have gone through menopause.

May cause osteoporosis, hot flushes, tiredness and joint pains.

Biological therapy – Trastuzumab (Herceptin) Used to reduce the risk of breast cancer coming back in women whose breast cancer cells have a large number of HER2 receptors| on their surface.

 

Stops the cancer cells from dividing and growing.

 

Encourages the body’s own immune cells to destroy the cancer cells.

 

 

Specific treatment only for women whose breast cancer cells have a large number of HER2 receptors on their surface.

Initially mild flu-like symptoms such as headache, high temperature (fever) and chills, or feeling sick. Later can be diarrhea, headaches and feeling sick.

May lead to mild heart problems in some women.

 

E TCM interpretation of cancer

Gascoigne (2001) believes that cancer is a manifestation of an underlying energetic imbalance and that emotional strains such as bereavement, separation and other major life changes often have a significant role in cancer. He also states that although there are many different syndromes which can be diagnosed as cancer, the commonest one is stagnation of Blood or Phlegm with an underlying Yin or Yang deficiency.

Wolfe and Flaws (1998) also agree that emotional health is a core factor in cancer. Quoting Zhu Dan-xi (a famous 13th century physician) they conclude that the main cause of breast cancer is due to emotional stress and frustration and that the disease mechanism mainly involves the Spleen and the Liver. Emotional frustration, stress, depression and suppressed anger impede the flow of Liver Qi which can then lead to Qi stagnation in the breasts. Because Qi moves the Blood and body fluids then Qi stagnation can lead to Blood and body fluids also becoming stagnant in the breasts and turning into Phlegm. These Yin depressions can hinder the free flow of Yang Qi and can lead to local depressive Heat. They further explore the issue of why some women get benign tumours and others are malignant and conclude that toxins are the differentiating factor. Toxins are not only chemical or environmental agencies, but can also be internally generated. Exploring the work of Sun Bing-yan (one of the most famous TCM doctors specialising in cancer alive today) they say that Qi stagnation can lead to depressive heat, this can lead to damp heat which may implode becoming heat or damp heat toxins – such a transformation is inversely proportional to the health of the spleen.

In a fascinating book Li (2003) identifies several different causes dependant on full diagnosis of signs and symptoms including tongue and pulses – these include Liver Depression and Qi Stagnation, Phlegm Damp due to Spleen Deficiency, Disharmony of the Chong and Ren vessels, Accumulation of Stasis and Toxins and Depletion of Qi and Blood.

Complementary therapies

Li (2003) claims that Chinese medicine can be used both to alleviate side-effects of conventional medicine and as a supplementary treatment. Before surgery TCM would advise that Qi, the Liver and the Kidneys are all tonified by using Chinese herbs or acupuncture. This will help the body’s ability to withstand surgery, help recovery after surgery and reduce post-operative complications. TCM believes that surgery damages Qi and Blood and disrupts the functioning of the Zang-Fu organs so would advise post-surgery that acupuncture and/or herbs be taken which will tonify Blood and Qi and nourish Yin and Body Fluids.

In discussing Radiotherapy and Chemotherapy Li (2003) says that such treatments produce Heat toxins, damage and disrupt Qi and Blood, cause Spleen and Stomach disharmony, impair the generation of Body Fluids and disrupt and damage the Liver and Kidneys. Gascoigne (2001)  is in general agreement and adds that if the person is Blood deficient already then Yin deficiency may result. He classifies drugs such as Tamoxifen as having similar effects. Li (2003) says TCM treatments can reduce toxic reactions and adverse side-effects. There are two main TCM treatment principles a) Strengthen the Spleen and nourish the Kidneys in order to support Zheng(vital) Qi. b) Augment Qi and nourish the Blood. The National Foundation for Cancer Research (2011) reports there has been a major study recently (September 2010) showing that TCM medicine could reduce the unpleasant gastrointestinal side effects caused by chemotherapy given to colon and rectal cancer patients.

The American Cancer Society (2011) warns that a conventional doctor might have concerns that Chinese herbs can interact with conventional drugs. There have also been cases where Chinese herbs were contaminated with toxic metals or adulterated with Western drugs.

Another treatment considered by people is Naturopathy. Oncology Academy of Naturopathic Physicians (2011) shows that naturopaths even have their own cancer association – The Oncology Association of Naturopathic Physicians which was formed in the US in 2004 by naturopaths who specialise in Naturopathic Cancer treatment. Cancer Active (2010) in describing the Bristol Diet claims that naturopathy as well as helping to prevent cancer by having a healthy diet and lifestyle, can also be used to alleviate side effects of orthodox cancer treatments. The Bristol Cancer Care Centre(now the Penny Brohn Centre) has for over 30 years advocated the Bristol Diet to help rebalance the body, reduce carcinogens, enhance the immune system and reduce the side-effects of cancer treatment.

The American Cancer Society (2008) warns that a conventional doctor may have a few worries about naturopathic treatment. These would include the danger of excessive fasting, dietary restrictions, or use of enemas all of which are sometimes components of naturopathic treatment. A naturopath may proscribe herbs which can possibly interact with conventional medicine or, if unregulated, have harmful effects.

 

References

American Joint Committee on Cancer (2011) What is Cancer Staging, [online] Available at: http://www.cancerstaging.org/mission/whatis.html [Accessed: 19 November 2011].

American Cancer Society (2011) Chinese Herbal Medicine, [online] Available at: http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/chinese-herbal-medicine [Accessed: 23 November 2011].

Cancer Active (2010) The Bristol Diet, [online] Available at: http://www.canceractive.com/cancer-active-page-link.aspx?n=1911 [Accessed: 23 November 2011].

Cancerquest (2011) Cancer Treatment: Radiation Therapy, [online] Available at: http://www.cancerquest.org/printfriendly.cfm?printsub=142 [Accessed: 17 November 2011].

Gascoigne S (2001) The Clinical Medicine Guide – A Holistic Perspective as quoted in CMS Course Manualv2.1 Appendix 2.3b

Kumar P and Clark M L (2009) Clinical Medicine (Kumar and Clark’s Clinical Medicine). 7th Edition. Spain: Saunders Ltd

Li Peiwen (2003) Management of Cancer with Chinese Medicine, St.Albans: Donica Publishing

Longmore M, Wilkinson I B, Davidson E H, Foulkes A, Mafi A R (2010). Oxford Handbook of Clinical Medicine (Oxford Handbooks). 8th Edition. Oxford: Oxford University Press

Macmillan Cancer Support1 (2011) How breast cancer is diagnosed – Cancer Information – Macmillan Cancer Support, [online] Available at: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Breast/Symptomsdiagnosis/Diagnosis.aspx [Accessed: 17 November 2011].

Macmillan Cancer Support2 (2011) Biological therapy Trastuzumab (Herceptin®) , [online] Available at: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Breast/Treatingbreastcancer/Herceptin.aspx [Accessed: 17 November 2011].

Macmillan Cancer Support3 (2011) Choice of treatment, [online] Available at: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Breast/Treatingbreastcancer/Surgery/Choiceofsurgery.aspx [Accessed: 20 November 2011].

Macmillan Cancer Support4 (2011) Chemotherapy for breast cancer, [online] Available at: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Breast/Treatingbreastcancer/Chemotherapyforbreastcancer.aspx [Accessed: 17 November 2011].

National Foundation for Cancer Research (2011) >NFCR Scientist Verifies TCM Breakthrough for Mainstream Cancer Treatment, [online] Available at: http://www.nfcr.org/index.php?option=com_content&view=article&id=899:newsflash-template&catid=3:newsflash [Accessed: 17 November 2011].

Oncology Academy of Naturopathic Physicians (2011) About Us, [online] Available at: http://www.oncanp.org/about.html [Accessed: 24 November 2011]. Bottom of Form

 

Tortora, G J and Grabowsji, S R (1992) Principles of Anatomy & Physiology. 7th Edition. New York: Harpercollins College Div.

Waugh A and Wilson K J W (2006)  Anatomy and Physiology in Health and Illness 10th edition Oxford: Churchill Livingstone

Wolfe H L and Flaws B(1998) Better Breast Health Naturally With Chinese Medicine Boulder,Colorado: Blue Poppy Press