Cancer Helper

Anal cancer is cancer that grows in the anus. The anus is actually a canal (anal canal) that connects the lower part of the large intestine (rectum) to the outside of the body, allowing the feces to pass from the large intestine during a bowel movement. Feces are formed in the longest part of the large intestine (colon), stored in the rectum, and pass through the anus.

The anus is about an inch and a half long and is lined with a type of cell called squamous cells. These cells are similar to the ones lining the bladder, vagina, urethra, and even the mouth and throat. They form a transition from the cells of the rectum to the cells of the skin outside the anus. Glands and ducts (tubes leading from the glands) are found under the epithelium. These glands produce mucous, which acts as a lubricating fluid.

The skin on the outside of the anus is sometimes called perianal skin (”peri-” means “near”). The skin is also covered with squamous cells that are different from the ones lining the inside parts of the body.

The upper part of the anal canal, where it meets the rectum, is a transitional zone from rectum to anal canal. The lower end, called the anal margin, contains the sphincter. The sphincter is a circular muscle that keeps feces from coming out until it is relaxed during a bowel movement.

Many types of tumors can develop in the anus. Some of these tumors are benign (noncancerous). Others are cancerous, which means they can penetrate into surrounding tissues and can spread to other parts of the body. There are also some growths that start off benign but can develop into cancer. These are called precancerous conditions. This section discusses all of these types of abnormal growths.

Benign (Noncancerous) Anal Tumors

Polyps: Polyps are small, bumpy, or mushroom-like growths that develop in the epithelium or just under it. There are several kinds, depending on their cause and location.

• Inflammatory polyps arise because of inflammation from injury or infection.
• Lymphoid polyps develop in lymph tissue (part of the immune system). Small nodules of lymph tissue are normally present under the anal epithelium.

Skin tags are benign growths of connective tissue that are covered by a layer of squamous epithelium. Skin tags are also called fibroepithelial polyps.

Condylomas: Condylomas (also called warts) are growths just outside the anus from infection by a human papillomavirus (HPV). People who have had condylomas are more likely to develop anal cancer (see below).

Adnexal tumors: Adnexal tumors are usually benign growths that start in hair follicles or sweat glands of the skin. These tumors stay in the perianal skin area and do not grow into the anal region.

In rare cases, benign tumors can grow in the various other tissues of the anus. These include:

Leiomyomas: Leiomyomas develop from smooth muscle tissue.

Granular cell tumors: Granular cell tumors are composed of cells that contain lots of granules. Under a microscope, these granules look like tiny spots that fill the cells. Scientists have not yet discovered exactly what type of tissue these tumors start growing in.

Hemangiomas: Hemangiomas develop from the lining cells of blood vessels.

Lipomas: Lipomas are tumors that start from fat cells.

Schwannomas: Schwannomas develop from cells that cover nerves.

Precancerous Anal Conditions

Sometimes abnormal changes of the anal epithelium are harmless in their early stages but may later develop into a cancer. A general term for these precancerous conditions of the epithelium is dysplasia. Some warts, for example, contain areas of dysplasia and can develop into cancer. Dysplasia occurring in the anus is also known as anal intraepithelial neoplasia or AIN. Most doctors feel that anal intraepithelial neoplasia will often develop into cancer.

Anal intraepithelial neoplasia is divided into 2 types ????? low grade and high grade. Low grade anal intraepithelial neoplasia is probably harmless, but many doctors feel that high-grade changes will eventually become cancer.

Malignant (Cancerous) Anal Tumors

Squamous cell carcinomas: Squamous cell carcinomas are the most common type of anal cancer. They account for most anal cancers. These tumors come from squamous cells of the epithelium that lines the anal margin and most of the anal canal. In its earliest stage, squamous cell carcinoma is known as carcinoma in situ, (pronounced “in SY-too”), meaning cancer in its original site, usually abbreviated as CIS. Another name for this condition is Bowen’s disease. The cancerous cells of carcinoma in situ are limited to the epithelium; they have not spread into any other tissues. Cells of invasive squamous cell carcinomas have already spread beyond the epithelium and are therefore no longer considered in situ.

Cloacogenic carcinomas: This is a sub-class of the squamous cell cancers that develop in the transitional zone, also called the cloaca. Approximately 25% to 33% of anal tumors develop in the transitional zone; only some of them are considered cloacogenic carcinomas.

Adenocarcinomas: A small number of anal cancers are known as adenocarcinomas. (The prefix “adeno-” means gland.) Adenocarcinomas can develop in glands located under the anal epithelium that release their secretions into the anal canal. They can also arise in apocrine glands (a type of sweat gland of the perianal skin). Most often they arise from the rectum and are treated as rectal carcinomas.

Paget disease is a type of apocrine gland carcinoma that spreads through the surface layer of the skin. Paget disease can affect skin anywhere in the body but most often affects skin of the perianal area, vulva, and the breasts. This condition should not be confused with Paget disease of the bone, an entirely different disease also named after Dr. James Paget.

Basal cell carcinomas: Basal cell carcinomas are a type of skin cancer that can develop from the perianal skin. These tumors are much more common in areas of skin that are exposed to sun, such as the face and hands, and account for only a small percentage of anal cancers..

Malignant melanoma: This cancer develops from cells in the skin or anal lining that produce the brown pigment called melanin. About 1% to 2% of anal cancers are melanomas. Melanomas are far more common on parts of the body that are exposed to sun. If melanomas are found at an early stage before they have invaded deeply into the skin or spread to lymph nodes, the outlook for long-term survival is excellent. As more people learn to recognize melanomas, more of these cancers are being found early by patients who examine their own skin. Most anal melanomas are found at a late stage because they are hard to see. If you would like more information on melanoma skin cancer, see the American Cancer Society document, “Melanoma Skin Cancer.”

Gastrointestinal stromal tumors: These are rare anal cancers that are much more commonly found in the stomach or small intestine.

Advanced cancer can be very scary and may very well be the hardest problem you and you family have ever faced. If you and your family have ongoing concerns that interfere with your lives, or if you may simply want to maximize your communication and coping, you should talk with a licensed mental health professional. Being able to talk with an expert about your unique situation may bring you a great deal of comfort. Social workers, psychologists, and psychiatrists are all licensed mental health professionals who can be located through your oncologist or through the nearest large hospital in your area. Even one session with a licensed mental health professional can help you and your family to focus on what matters most in your lives. Your oncologist will be happy to work with you to find the right professional for you.

Dealing With Worry and the Unknown

Learning that you have advanced cancer may make you feel lost and afraid. This is natural. You may have questions such as:

• What is going to happen to me?
• Have I done everything I should have done?
• What are the other options?
• Am I going to die?
• How much control will I have over my own life?
• Will my wishes be followed?
• How much pain and suffering will I have?
• What if I feel that I can’t take much more treatment?
• How can I burden my family in this way?
• Will this be too much for my family to bear?
• What am I going to do about money?
• How long am I going to have to go through this?
• What happens when I die?

The list of fears may seem overwhelming even to think about, much less experience. Worrying may make it hard for you to focus. You may even have tight muscles, trembling, and shakiness. Restlessness, shortness of breath, heart racing, sweating, dry mouth, and grouchiness are other signs of worry. But few people have all of these symptoms. Fortunately, there are professionals who can help you manage these concerns. In addition to your doctor and nurse, there are social workers, psychologists, psychiatrists, and pastoral counselors who are specially trained to help you talk about your concerns, control your fears, and make meaning of the experience. They are also available to support your family. Your doctor will know the local mental heath experts in your community.

Likewise, a loved one may have similar feelings in his or her role as caregiver, money manager, spouse, child, or breadwinner.

Managing worry:

• Sometimes just talking about feelings helps to relieve worry.
• Trying to relax with deep breathing and relaxing body postures can be helpful. It works best if you practice and do it regularly.
• It’s important to let yourself feel sad and frustrated, without feeling guilty about it.
• Picking the right person to talk with can be important. For some, that person will be a minister or a best friend. For others, it will be a family member.
• Spiritual support is helpful for many people.
• If your worry is upsetting to you or your family and lasts for long periods of time, it is important that you request a referral to a mental health professional who is specially trained to work with cancer patients.

Along with these measures, a doctor may be able to suggest medicines to treat anxiety and depression. Short-term use of these drugs is rarely a problem. It can be just what you need to regroup.

Finding Hope

Hope is a necessary part of everyday life. Hope gets many of us out of bed in the morning and keeps us going throughout the day.

Even if you have advanced cancer, you can still have hopes and dreams. Some of these may have changed since you learned of your cancer. Your hope may be to have a pain-free day. Another hope could be to do something special with a family member. Just talking openly can be a hope that people with cancer and their families can share. There may also be real hope for relief of symptoms and slowing down the growth of the cancer.

Coping with Pain and Discomfort

Advanced illness can cause much discomfort. Dealing with these symptoms is a challenge. Physical pain causes distress to the mind as well. It is essential that you work with your health care team to manage your physical symptoms. Severe physical symptoms like pain can make it impossible to have any quality of life. By combining medical treatment with coping skills you will be able to manage your physical symptoms best.

Distract yourself: Getting your mind off the pain is always a good idea. It usually hurts more when you are focused on your pain. If you are watching an interesting movie while in pain, you may even forget about it for a while. Visits from friends and family can serve the same purpose.

Get information: Knowing why you have a problem and what you can do about it can relieve stress. Don’t be afraid to ask why something is happening.

Take action: Doing something, sometimes anything, about a problem can help you feel more in control. For example, if the new drug you are taking for your stomach isn’t helping, ask to try something else.

Take it one step at a time: It’s easy to get overwhelmed if you focus on all the discomforts at once. Tackling one problem at a time makes it seem more possible that all the problems can be helped.

Talk with others: Sometimes, it’s a relief just to talk about how discouraged and frustrated you feel about your symptoms. Many people are good listeners and can listen without passing judgment or giving advice.

Express yourself in other ways: For some, talking is not easy. Writing in a journal, painting, or meditating may be other ways for you express your feelings.

Find your sense of humor: Humor is a tried and true coping skill for rough times. Even when life seems bleak, there is usually something that can lighten the mood and relieve stress.

Practice meditation: By focusing your mind on pleasant scenes you can direct your attention away from unpleasant feeling and thoughts. These mini-vacations will enable you to get a needed rest, both physically and emotionally.

Relieving Depression

Feeling sad and down at times is normal with illness and the side effects of treatment. But there is room for happiness even with advanced cancer. You don’t have to feel down all the time. Because depression can be a very serious problem, it is important to have a trained mental health professional assess a person who appears to be depressed regardless of the cause.

About 1 in 4 people with cancer will become depressed. (The numbers are higher in those with advanced cancer.) All depression can be treated. The symptoms of depression are listed below. Family and friends should watch out for these symptoms. They can encourage the cancer patient to seek a doctor’s help.

Symptoms of clinical depression include:

• ongoing sad or “empty” mood
• feeling hopeless and helpless
• no interest or pleasure in everyday things
• less energy, feeling tired, being “slowed down”
• trouble sleeping, early waking, or oversleeping
• loss of appetite or overeating
• trouble focusing, remembering, or making decisions
• feeling guilty, worthless, or helpless
• grouchiness
• crying a lot
• ongoing aches and pains for no clear reason
• thoughts of death or suicide; trying to kill yourself

Please see a mental health professional if you have 5 or more of these symptoms for 2 weeks or longer.

Treatment for depression:

• medicine
• teaching problem-solving skills
• counseling

People treated for depression are often surprised at how much better they feel. Depression and feelings of sadness can become a way of life. It doesn’t have to be that way.

Feeling Less Alone

Depression and feeling alone often go hand in hand. Depression can make you feel the need to withdraw from others. But the illness and the demands of treatment sometimes cause you to be alone. People with cancer can end up alone even if they want to be with others. This can happen because of physical problems, lack of transportation, or treatment schedules.

You can feel alone even when you are with well-meaning friends and family. You may have a hard time sharing your feelings about your cancer. Others might be uncomfortable hearing about your illness. This isolation within the company of others can sometimes feel worse than really being alone.

Sometimes a person with cancer needs to ask for permission from others to talk more freely. It is also helpful if a friend or family member arranges for others to visit you. Trying to do things outside the home can also make you feel less alone.

Managing Guilt

Both people with cancer and those in their support circle often have feelings of guilt. If you have cancer, you might feel guilty about being ill. These feelings can last even when you know it isn’t your fault. Making others aware of your discomfort or telling loved ones that you need their help can make you feel guilty, too.

For the people caring for the patient, guilt feelings can be a daily struggle. Those who are healthy feel guilty about their good health. They often feel bad about not doing enough for their loved one. Yet, they can’t do any more. And sometimes they feel bad about resenting what they are doing.

Managing feelings of guilt:

• Sometimes just talking about the feelings of guilt can help. It can clear the air and ease everyone’s conscience. Sharing the common feeling can bring you closer together.
• Letting each other off the hook is helpful. You can tell each other that you know everyone is doing their best.
• For caregivers, sharing the work is important. Friends and family who want to help should be given specific tasks to lighten the main caregiver’s load.
• If guilt still persists, it is important that you meet with a trained mental health professional.

Facing Family Issues

Advanced cancer changes the way family members relate to one another. Families that solve conflict well and support each other do best in dealing with a loved one’s cancer. Families who find problem solving hard will have more trouble. You may wish to meet with a counselor to work together to plan how to best support each other and to anticipate problems.

Roles within the family will change. How family members take on new tasks and fill in for the person with cancer affects how they will adjust to losing that person.

For the person with cancer, the changes in family roles can trigger the grief that comes with loss. For example, a bedridden woman may feel anguished about not being the wife and mother she once was. Understanding this and finding ways for her to still contribute and feel included may help both her and her family.

Maintaining Sexual Feelings and Closeness

During advanced illness, a sexual relationship will change. This can be due to physical symptoms, such as fatigue, trouble moving, or pain. It can also come from holding back emotions. Very often sexual desire may decrease but this does not mean that the need for physical closeness and touching will change. In fact, the need to be held and touched may increase. Talking about feelings and continuing to touch each other can help with feeling alone and keep you feeling close. However, if you have any doubt about if it is OK to act in a sexual manner or to simply touch, just ask and talk about it. Never ever assume.

Getting Through a Long Illness

Illness that goes on for months or even years puts huge stress on the family. The longer the stress lasts, the more at risk the family is for mental distress. Family members may become exhausted in body and mind. Fatigue added to worry and fear can take a toll. Find ways to get support for the caregivers. Keep asking how everyone is holding up.

Finding Strength in the Spiritual

Spiritual questions are common as a person tries to make sense of both the illness and his or her life. This may be true not only for the person with cancer, but for loved ones as well.

Here are some suggestions for people who may find comfort in spiritual support:

• Help from a spiritual counselor can be timely. He or she can help you find comforting answers to hard questions.
• Religious practices, such as forgiveness or confession, may be reassuring.
• A search for the meaning of suffering can result in a spiritual answer that is comforting.
• Believing in life after death and an end to human suffering on earth is helpful for many.

Strength through spiritual support and a community of people who are there to help can be priceless to family members.

Facing Death

Anyone with advanced cancer faces the reality that he or she will die. Family members must recognize this too. Even if the person with cancer is doing well, death is a likely part of the future at some point. Thinking about death is frightening and painful for many. Patients and families worry about suffering before death and being alone in death. But sometimes the illness and suffering have gone on for so long that everyone sees death as a relief.

Many people with cancer want to be at home until the end. A long illness and dying at home can be easier with the support of family and medical staff. Often everyone’s goal is to help the person with cancer die at home, with loved ones, and with little or no pain.

This is a brief description of where the cancers are likely to spread.

Bladder: Bladder cancer tends to grow locally and invade local tissues such as the pelvic wall. It also spreads to lungs, liver, and bone.

Brain: Brain cancer rarely spreads outside the brain. It mainly grows throughout the brain.

Breast: Breast cancer most commonly spreads to the bone but also can spread to the liver, lung, and brain. As the cancer progresses, it may affect any organ, even the eye. It can also spread to the skin near where the cancer started.

Colorectal: The most common site for colon cancer to spread is to the liver. Next sites are bone and lung. Spread to the brain is uncommon. Rectal cancer spreads commonly to the lung, brain, and bone. But its major site of spread is in the pelvis, where the rectal cancer started. This can be painful because it grows into nerves and bones in the area.

Esophagus: Esophageal cancer mostly grows locally. As it progresses, swallowing may become difficult. This can occur suddenly or gradually over several months.

Kidney: Kidney or renal cancer can grow locally and invade directly into surrounding tissues. When it spreads, the lungs and bones are the most common sites.

Leukemia: Leukemias advance by filling the bone marrow with leukemia cells. As the bone marrow is replaced, it cannot produce normal cells, such as oxygen-carrying red cells, infection-fighting white cells, or platelets that stop bleeding.

Liver: Liver cancer doesn?t often spread outside the liver; rather, it grows in the liver as it becomes advanced.

Lung: Lung cancer can spread to any organ of the body, but most often it will spread to the liver, bones, and brain. It will grow in the lung and spread to other parts of the lung. It can also grow into the sac around the heart (pericardium).

Lymphoma: Lymphomas tend to stay in the lymph nodes and bone marrow. They will spread to other organs when they are very far advanced. The involvement of lymph nodes can be very troublesome because this can cause fluid to accumulate in the abdomen and lungs, as well as in the arms and legs.

Melanoma: Melanoma can spread anywhere in the body. It first tends to go to local lymph nodes but then can spread through the blood to the brain, lungs, liver, and bone.

Mouth and throat: Cancers of the mouth, throat, or nasal passages tend to grow locally. When they spread, it is usually to the lungs.

Multiple myeloma: Multiple myeloma mainly stays in the bone where it started and rarely spreads elsewhere. But myeloma cells produce substances that cause the bones to weaken and fracture. Because it dissolves bones, the release of so much calcium causes hypercalcemia. Myeloma protein produced in large amounts can damage the kidneys. This reduces a person’s ability to dispose of excess salt, fluid, and body waste products. Myeloma patients are about 15 times more likely to develop infections. The most common and serious of these is pneumonia.

Ovarian: Ovarian cancer, in the advanced stage, most often spreads to the lining and organs of the abdomen and can cause a build-up of fluid and swelling in the abdomen. It can also spread to the outer lining of the lung and cause fluid to accumulate there. It much less often spreads outside the abdomen and pelvis.

Pancreatic: Pancreatic cancer mainly stays in the abdomen and grows locally as well as spreading to the liver. It can also spread to the lungs, bones, and brain.

Prostate: Prostate cancer, when it spreads, usually goes to the bones. Much less often, it will spread to other organs, including the brain.

Stomach: Gastric or stomach cancer tends to spread locally and within the abdomen. The next areas it goes to are the liver and lungs. Spread to bone and brain is less common.

This section talks about the symptoms you might have when cancer spreads to different places in your body. Not everyone will get all the symptoms. Some of the information may not apply to you. Your doctor can tell you the most about your condition. Be sure to have regular checkups to find and treat the spread of cancer.

Treatment is covered briefly in this section. For more about treatment for a given symptom, see the section,
“Managing Physical Problems of Advanced Cancer.”

If the Cancer Has Spread Into the Abdomen

When fluid has collected and built up in the abdomen, it is called ascites. This extra fluid can make your belly expand and is uncomfortable. It can also make it hard to breathe.

Treatment: The doctor removes the fluid through a needle. This relieves the problem for a while, but it will likely come back.

Cancer can spread to the bowels and cause blockage (obstruction). This causes very bad cramping and vomiting. If the cancer has only spread to the colon (large intestine), surgery may help.

Treatment: Colostomy or bypassing the blockage with surgery can help, if you are strong enough to have surgery.

Cancer can also spread to or block the thin tubes (ureters) that carry urine from the kidneys to the bladder. If this happens, you may stop passing urine. Also, you will feel very tired and sick to your stomach.

Treatment: A tube can be threaded through the ureters to allow urine to flow again.

If the Cancer Has Spread to Bones

Your main symptom will be pain where the cancer is. Even though the cancer may have spread to many places in the bone, it usually hurts in only a few. Sometimes a bone will weaken and break. This happens with bones that support your weight, like the leg bones. But it can also happen to the bones of the back. The first symptom may be a sudden very bad pain in the middle of your back.
See “Broken Bones” in the section, “Managing Physical Problems of Advanced Cancer”.

Treatment:

• drugs that strengthen bones (bisphosphonates)
• radioactive compounds, such as strontium-89, that are given into a vein
• radiation therapy to an especially painful bone

Preventing broken bones:

• Stay away from activity that is hard on your bones (examples: heavy lifting, jogging).
• Any very weak bone may need a protective rod put in by a bone surgeon.

If the Cancer Has Spread to the Brain

The most common symptom is a headache or losing movement in part of your body, like an arm or leg. The other main symptom is sleepiness. You may have problems with other things, too. These can include hearing, eyesight, and even passing urine.

Treatment: Radiation treatment is best for these symptoms. Cortisone-like drugs, such as dexamethasone, can often help with symptoms.

Seizures are another symptom of cancer in the brain. They aren’t common. But they can be very upsetting and scary both to you and to those around you.

Treatment: Medicines called anticonvulsants can prevent seizures.

If the Cancer Has Spread to the Liver

You may lose your appetite and feel tired. Some patients feel pain in the upper right part of the abdomen, where the liver is. Usually the pain is not bad and is less of a problem than the tiredness and appetite loss. If there is a lot of cancer in the liver, your skin may turn yellow. This is called jaundice.

Treatment:

• If there are fewer than 4 to 5 tumors, they can sometimes be treated by surgery, freezing (cryotherapy), or radio waves.
• For more tumors, chemotherapy may help. This may be given into a vein or directly into a blood vessel leading to the liver.
• Plugging up the blood supply to the cancer with gelfoam (embolization)

See also treatment information for your specific symptoms in the “Managing Physical Problems of Advanced Cancer” section above.

If the Cancer Has Spread to the Chest or Lungs

The cancer may cause fluid to build up around the lungs. This will make you short of breath. (Also see “Trouble Breathing” in the “Managing Physical Problems of Advanced Cancer” section.)

Treatment:

• Your doctor can remove the fluid that has built up around the lungs through a needle.
• Chemotherapy and hormone therapy may be helpful.
• External radiation therapy
• Surgery may be possible.
• Often, a chemical or talc that can prevent further fluid build-up can be put into the space.

The cancer itself can cause shortness of breath and chest pain as it spreads to more and more lung tissue.

Treatment:

• oxygen
• opioids, such as morphine, for pain

The cancer can also spread to one of the large tubes that air passes through as it goes into your lung. This will make you short of breath. The lung may even collapse because it isn’t being filled up as you breathe.

Treatment:

• The tumor can sometimes be partly removed with laser treatment.
• Radiation therapy may shrink the tumor.

The cancer can also grow into the sac surrounding the heart. (This sac is called the pericardium.) This is not common but it can cause fluid to build up around the heart. Symptoms include shortness of breath, low blood pressure, swelling of your body, and feeling tired.

Treatment: Removing the fluid with a needle can relieve this. This usually is done in a hospital setting because the heartbeat needs to be monitored. Often this is followed with radiation and/or putting a chemical into the pericardium that prevents further fluid build-up.

If the Cancer Has Spread to the Skin

You will have lumps on the skin. Usually this does not cause symptoms. Sometimes breast cancer can come back in the skin over the chest and get infected. The open sores that result can smell bad.

Treatment:

• Radiation treatment to the sores can shrink them and dry them out. This can only be done if you haven’t had any radiation treatment before.
• Certain chemotherapy drugs can be put directly on the tumors and help dry them up.
• Antibiotics can help take away the smell. The antibiotics may either be pills or an ointment put directly on the sores.

This section describes the major problems that can arise from advanced cancer. You may have some of these problems and symptoms or none of them. The following section, called “Problems Grouped by Location of Cancer,” describes problems that are related to specific types of cancer.

Broken Bones (Fractures)

When cancer invades bones, it can weaken them. This sometimes leads to fractures, particularly in the leg bones near the hip. That’s because these bones support your weight. You may have very bad pain for a while before the fracture occurs. At that time, an x-ray may show that the bone is likely to break.

Treatment: The best treatment is to prevent the fracture. This is done through surgery. Surgeons place a metal rod through the weakened part of the bone. They do this while you are asleep under general anesthesia.

If the bone has already broken, then something else will be done to support the bone. Usually surgeons place an external steel support over the fracture.

External beam radiation may also be given to prevent any further damage by the cancer. Usually about 10 to 15 treatments are needed although some doctors give the total dose of radiation in only 1 or 2 treatments. The radiation therapy will not strengthen the bone. Surgery will still be needed to prevent a fracture.

Medicines or the cancer itself may cause confusion, dizziness, or weakness, which can lead to falls and accidents. Falls can cause fractures, especially to bones made weak by the cancer. Talk with your cancer care team about safety equipment you can use at home. Some examples are shower chairs, walkers, and handrails.

Blocked Bowel (Bowel Obstruction)

When cancer blocks either the small intestine or large intestine (colon), digested food or stool cannot move through. This is called bowel obstruction. The symptoms include severe cramping, pain in the abdomen, and vomiting. The vomit may contain digested food, bile, and sometimes stool. Bowel obstruction occurs most often with abdominal or pelvic cancers.

Treatment: It is very hard to solve this problem with surgery. And many patients are too sick to handle surgery. Others have such a poor outlook that it may not help much. Most studies have shown that patients with advanced cancer who develop this problem live only a short time. The decision to have surgery should be weighed against the chances of returning to a comfortable life.

An operation called a colostomy may help if only the colon is blocked. In this operation the surgeon cuts the colon above the blockage. The cut end is then brought to the outside of the abdomen. Your stool can empty into a bag that is put around the opening.

Often, only treating the symptoms is the best choice for many patients. This is called supportive care. For example, doctors may remove the stomach’s contents through a tube placed through your nose and attached to a suction device. This often relieves nausea and vomiting. The next step would be to stop eating and to drink only small amounts to relieve thirst. You can take medicines for pain and nausea in a shot (injection).

Fatigue (Tiredness)

Fatigue is one of the most common symptoms of cancer patients. It can make it hard for you to find the energy to do the things you normally do. Fatigue can be caused by:

• the cancer itself
• the cancer treatment
• not eating well
• pain
• feeling depressed
• not enough red blood cells (anemia)

Treatment: There is no one cure for fatigue. In each case, treatment is aimed at the cause of the fatigue.

• Blood transfusions can help some patients who have low red blood cell counts (anemia). Other patients can take medicines that help the body make more red blood cells. Talk with your doctor about treatments for very bad anemia.
• Light or medium exercise with a lot of rest breaks in between can often help with fatigue.
• You can save energy by doing what needs to be done first and letting other things wait. Try to think of energy as gold. You want to invest only in what’s most important to you.
• Spread your activities all through the day rather than trying to get them done all at once.
• Sometimes stimulant drugs such as Ritalin, Provigil, or Dexedrine can help.

Unfortunately, doctors haven’t yet explained why the cancer itself causes fatigue. Some of this may be caused by substances called cytokines. The body produces these in response to the cancer, much as they are produced in the course of an infection such as influenza.

Too Much Calcium in the Blood (Hypercalcemia)

Cancer patients may have too much calcium in their blood for different reasons. Most often, it is related to cancer that has spread to the bones. This causes calcium to be released from the bones into the bloodstream. Other times the cancer makes a substance that causes high calcium levels. Often, blood levels of calcium can get so high that it is dangerous.

Early symptoms of too much calcium include:

• constipation
• passing urine very often
• feeling sluggish
• feeling thirsty all the time and drinking large amounts of fluid

Late signs and symptoms are coma and kidney failure.

Treatment: Giving fluids and certain drugs (Aredia or Zometa) can quickly bring blood calcium down. These are usually given into the veins by intravenous (IV) infusion.

If the cancer can’t be treated, the problem will come back and you will have to treat the blood calcium problem again. Sometimes a high blood calcium level can be the first sign of cancer. Treatment of the cancer will also treat the calcium problem.

Nausea and Vomiting

Advanced cancer can cause nausea and vomiting, either from radiation or chemotherapy treatments or from the cancer itself. Nausea and vomiting are most commonly caused by the treatments themselves and they generally get better the farther you are away from the treatment.

Nausea and vomiting are problems for many cancer patients, especially after treatment. In a small number of cancer patients, just thinking about getting their cancer treatments can make them feel nauseated. But there is effective treatment for this problem.

Too much vomiting can be dangerous. It can cause you to lose too much water (dehydration) or to breathe in food or liquids (aspiration).

Treatment for nausea:

• Try bland foods, such as dry toast, crackers, Popsicles, gelatin, or cold clear liquids.
• Eat several small meals and snacks at bedtime if you get sick only between meals.
• Eat things that smell pleasant, such as lemon drops or mints.
• Eat food cold or at room temperature to make the smell and taste weaker.
• Ask the doctor about medicines to help with nausea.
• Try to rest quietly for at least an hour after each meal.
• Learn meditation and relaxation techniques.
• Distract yourself with soft music, a favorite TV program, or company.

Treatment for vomiting:

• If you are in bed, lie on your side so that you won’t breathe in or swallow your vomit.
• Sometimes taking a medicine by mouth (orally) can bring on nausea or vomiting. Ask the doctor to prescribe your medicines as suppositories. (Suppositories are drugs that you can take through your rectum. The medicine in the suppository is absorbed into the blood stream and then travels to the brain to stop the nausea.)
• Learn meditation, self-hypnosis, and relaxation techniques.
• Eat ice chips or frozen juice chips that you can munch on slowly.

Things to avoid:

• Don’t force yourself to eat or drink when you have an upset stomach or are vomiting.
• Don’t lie flat on your back.
• Stay away from foods that have strong smells.
• Don’t eat foods that are sweet, fatty, salty, or spicy.
• Stop eating for 4 to 8 hours if you are vomiting a lot. After that time, try clear liquids.

Call the doctor if you:

• breathe in or swallow vomit
• throw up more than 3 times an hour for 3 hours or longer
• see blood or something that looks like coffee grounds in your vomit
• can’t keep down more than 4 cups of liquid or ice chips in a day
• can’t eat for more than 2 days
• can’t take your medicines
• feel weak or dizzy

The American Cancer Society has more information on how to manage nausea and vomiting. Call 1-800-ACS-2345 and ask for “Nutrition for the Person With Cancer: A Guide for Patients and Families” and “Nausea and Vomiting Treatment Guidelines for Patients With Cancer.”

Pain

There are many ways to ease pain caused by cancer. Sometimes pain is relieved by treatments that kill cancer cells (such as chemotherapy or radiation therapy) or slow their growth (such as hormone therapy or bisphosphonates). Don’t be afraid to use medicines or other treatments, including complementary therapies, to help with your pain. Getting effective pain relief will help you feel better. It will make it easier for you to focus on the things that are important in your life. Some studies show that cancer patients who get effective pain treatment may live longer than those who do not. The first and most important step is letting your cancer care team know about your pain.

Treatment: Medicine taken by mouth is the most common way to treat pain. Often 2 or more drugs are used together. Other ways to help with pain include massage, heat and cold, and changing your body position.

Usually your doctor will start with drugs such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin). If these aren’t helping, you will likely be given an opioid such as codeine, hydrocodone, morphine, or oxycodone. Codeine and hydrocodone are considered “mild” opioids, while morphine and oxycodone are stronger. Opioids are considered the best drugs for helping cancer patients with pain. Unless you have a history of drug or alcohol abuse, you can take these drugs without worrying about getting addicted. Discuss any of your concerns with your doctor or nurse. It is rare for cancer patients to develop addiction to opioids. With all pain medicines, it is very important that you take the medicine regularly for these reasons:

• so you maintain enough of the medicine in your bloodstream to keep your pain controlled
• so the pain won’t become so bad that you will have to take more pain medicine than you normally do to get the pain controlled.

Opioids can make you drowsy. They can also cause nausea and constipation. Most of the drowsiness usually goes away after a few days. But it may not go away if you are taking high doses. You may have to choose between having less pain and being drowsy or having more pain and being more alert. The constipation can be helped by regular use of stool softeners, fiber, laxatives, drinking plenty of liquids, and being active.

The best treatment for you depends on the type of pain you are having and how bad it is. Tell your cancer care team if the methods that you are using are not working.

Doctors have learned that not all patients respond to pain medicines the same way. Some medicines work better for some patients while others are less effective. Research has shown that this may be due to small genetic differences among people. This means that if one pain medicine, particularly an opioid, isn’t helping you, it may be worthwhile to try a different opioid.

Also, some people require much higher doses of opioids than others. Do not be put off if you seem to be taking a large amount of drugs. It has nothing to do with you being intolerant of pain or a ?complainer.? It just means that your body needs more medicine than average.

The American Cancer Society has more detailed information on how to manage pain. Call 1-800-ACS-2345 and ask for “Pain Control: A Guide for People With Cancer and Their Families” and “Cancer Pain Treatment Guidelines for Patients.”

Paralysis Because of Pressure on the Spinal Cord

Cancer sometimes spreads to the bones in the spine. As the tumor grows, it can put pressure on the nerves in the spinal cord. Symptoms can range from pain to weakness and paralysis (not being able to move). This also affects the nerves to your bladder so you will have trouble urinating. Early treatment can help reduce permanent nerve damage.

Symptoms to watch for:

• trouble passing urine
• numbness or weakness of the legs
• very bad pain in the middle of your lower back

Tell your doctor right away if you have these symptoms. An MRI can usually tell if the cancer is pressing on your spinal cord. This is considered a medical emergency and treatment should begin promptly.

Treatment:

• steroids (prednisone or dexamethasone) to bring down swelling and treat pain
• radiation therapy to shrink the tumor causing the problem
• sometimes surgery is used to remove all or part of the tumor

Skin Problems

People with long-term illnesses often get skin problems from sitting or lying too much in one position. Cancer patients may also get skin problems from:

• not eating well
• not being able to move around
• swelling
• some cancer treatments

Treatment: Talk with your cancer care team. They can recommend a skin care program for your special needs. The most important thing you can do is change positions often when you are sitting or lying.

Blocked Blood Flow to the Heart (Superior Vena Cava Obstruction)

The main vein that returns blood to the heart from the upper body is called the superior vena cava. It runs through the upper middle chest. Pressure from tumors in the chest or lung can block the blood flow in this vein. This will cause blood to back up in the lungs, face, and arms.

Symptoms include:

• shortness of breath
• a feeling of fullness in the head
• swelling in the face and arms
• coughing
• chest pain

Treatment: Radiation therapy and/or chemotherapy can help shrink the tumor. If this is not possible, you may have a metal tube (stent) placed in the vein. This tube is inserted through a large vein in your arm or neck and then threaded through the obstruction.

Trouble Breathing (Dyspnea)

Trouble breathing can be caused by a tumor blocking the airway or by a buildup of fluid around the lungs. Some patients with a very low red blood cell count (severe anemia) may also feel short of breath. A tumor blocking blood flow to the heart is another possible cause (see “Blocked Blood Flow to the Heart” above).

Treatment: When it’s possible, treating the cause will help relieve shortness of breath. Sometimes external beam radiation or laser treatment (given through a bronchoscope) can shrink a tumor in the lung.

Patients with fluid around the lungs may feel better after having this fluid removed. After numbing the skin, the doctor simply places a needle into the chest and drains the fluid.

Oxygen is very helpful. It is given through a little tube that goes just inside the nose.

Opioids, like morphine, are the most helpful drugs to relieve the feeling of shortness of breath. Anti-anxiety medicines, like Valium, can also help.

Having trouble breathing can make you anxious and worried. You may even feel like you are going to panic. Some patients find these complementary methods helpful to relieve anxiety related to breathing difficulties:

• relaxation methods
• biofeedback
• guided imagery
• therapeutic touch
• aromatherapy
• music and art therapy
• distraction (watching movies, television, reading, etc.)
• a fan blowing air on you

Weight Loss and Not Eating Well (Poor Nutrition)

As cancer gets worse, many people feel weak, lose their appetite, and lose a lot of weight. The reason for this is not known, but it may be caused by:

• substances released by the cancer into the blood
• no longer being able to absorb nutrients from food

Treatment: It is very hard to treat this problem. Feeding through an IV (intravenous) tube rarely helps. And it can burden patients with needles, tubes, and other supplies. Feeding through a stomach tube is also uncomfortable and rarely helpful.

Sometimes, the best thing you can do is to eat smaller amounts more often. Avoid low-calorie or low-fat foods. This is the time for high-calorie foods and vitamins.

One drug that has been helpful is Megace (megestrol acetate). In high doses, it can bring back appetite in some patients. Drugs that help the stomach empty, such as Reglan (metoclopramide), can also help improve appetite.

Goals of Treatment

Advanced cancer is not likely to be cured but it can frequently be controlled. The physical symptoms can almost always be well managed. At any stage of cancer, the goal of any treatment should be clear to both you and your family. You should know if the goal is to cure your cancer, extend your life, or relieve symptoms. This can sometimes be confusing, because some treatments used to cure cancer may also be used to relieve symptoms.

Some people believe that nothing more can be done if the cancer cannot be cured. So they stop all treatment. There are even doctors who think this way. But radiation, chemotherapy, surgery, and other treatments can often control symptoms. And relieving symptoms like pain, blocked bowels, upset stomach, and vomiting can help keep you more comfortable. Something can always be done to help your quality of life.

You have the right to be the decision-maker in planning your treatment. The goal of any cancer care is to give you the best possible quality of life. This is a very personal issue. You should tell the cancer care team what is important to you. Tell them what you want to be able to continue to do.

Some people decide that burdens placed on them by aggressive cancer treatments are not worth the unlikely benefits. They come to the conclusion that they no longer want aggressive treatment. Others want to continue cancer treatments. Some patients want to stay at home. Others choose to go to an assisted living center, a nursing home, or an inpatient hospice program if one is available. Again, you should make the choices that you feel are best and realistic for you.

You may decide that you don’t want any more treatment for your cancer. This may be hard for some of your loved ones to accept. But you have the right to decide what you want your quality of life to be. It is always best to include your family in these decisions.

Treatment choices for advanced cancer depend on where the cancer started and if and how much it has spread. As a general rule, cancer that has spread will need systemic therapy such as chemotherapy or hormone therapy. Systemic therapy is treatment that is taken by mouth or injected into the blood to reach cancer cells.

Surgery

In cancer treatment, surgery is generally used for cancer that is localized. Most of the time, the intent of surgery is to cure. Sometimes, though, surgery for a localized cancer may be used to remove only the major part of the tumor, leaving other treatments such as radiation and chemotherapy to get rid of the rest. If the cancer has spread to only one area and is not large, then it may be possible to remove it completely. For example, if cancer has spread to the liver and there are only 3 or 4 tumors, then it may be possible for the tumors to be removed surgically.

Surgery is not often used in treating advanced cancer. But sometimes surgery can be helpful. For example:

Surgery to relieve symptoms and improve your life: Surgery can improve your quality of life and may even help you live longer, even when cancer has spread too far to be cured with surgery. For example, cancer can sometimes block the bowel (intestine). This can be very painful. A surgeon may be able to bypass the blockage so the bowel can work normally again. Other times, it may be necessary to let the bowel drain outside the abdomen into a bag (colostomy). Sometimes, simple surgery is used to put feeding tubes in place. It can also be used to place smaller tubes into blood vessels for giving medicines to relieve pain.

Surgery to stop bleeding: This may be done if there is a lot of bleeding from the stomach or bowel.

Surgery to stop pain: Sometimes a tumor may be pressing on a nerve or be too close to the spinal cord. Either cutting the nerve or removing the tumor may relieve the pain or prevent paralysis. When doctors operate on pancreatic cancer, they will often cut the nerves that cause pain in the pancreas.

Surgery to prevent broken bones: Cancer may weaken bones, causing breaks (fractures) that tend to heal very poorly. An operation to put in a metal rod can prevent some fractures if the bone looks weak. This usually occurs in the thighbone. If the bone is already broken, surgery can rapidly relieve pain and help you be more active.

Whether surgery will help depends a lot on your condition. Major surgery is hardly ever successful if you are bedridden. The stress of the surgery can set you back even further. On the other hand, surgery may be a good idea if you are feeling fairly well and are active.

Radiation Therapy

Radiation therapy uses high-energy x-rays to kill cancer cells. For cancer that has not spread too far or too much, radiation therapy can sometimes cure the cancer. In advanced cancer, radiation therapy is often used to shrink tumors to reduce pain or other symptoms (called palliative care).

External beam radiation therapy is like having a regular x-ray except it lasts a little longer. Patients usually have treatments 5 days a week. Sometimes, this can be shortened to just 1 or 2 days.

The main side effects of radiation therapy are tiredness (fatigue) and skin that may feel slightly sunburned. Radiation to the head and neck area can damage the glands that make saliva and cause a sore throat or mouth sores. Some people have trouble swallowing or loose their ability to taste food. Radiation to the stomach area can cause nausea, vomiting, diarrhea, and possible damage to the intestines. Radiation to the chest area can cause scars in the lungs that may make some people short of breath. Brain radiation can sometimes cause problems with thinking or memory that start several month to years later.

Internal radiation therapy, or brachytherapy, uses small seeds of radioactive material placed directly into the cancer. The seeds can deliver a lot of radiation to a small area and spare the normal tissue around it.

Some radioactive materials (such as strontium-89 or Metastron) can be given into a vein. They are drawn to areas of bone that contain cancer. The radiation given off by the drug kills cancer cells and relieves bone pain but it will not cure cancer. If there has been spread to many bones, this may work better than only using external beam radiation that only treats a small area. Sometimes different types of radiation are used together.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they reach all parts of the body. This treatment is useful for cancer that is widespread. By shrinking the cancer it can relieve symptoms. It can even prolong life in some patients with far advanced cancer.

Drugs used in chemotherapy kill cancer cells. But they can also harm some of the normal, healthy cells in your body. This can cause side effects, such as:

• nausea and vomiting
• loss of appetite
• hair loss (the hair grows back after treatment ends)
• mouth sores
• increased chance of infection
• bleeding or bruising after small cuts or injuries
• tiredness (fatigue)

Your cancer care team can suggest many steps to ease side effects. For example, there are drugs to help reduce nausea and vomiting. Sometimes it will help for the doctor to change the dose or the time of day you take your medicines. It is important to balance these side effects against the symptoms you are trying to relieve.

Hormone Therapy

Estrogen, a hormone made by women’s ovaries, promotes growth of many breast cancers. Likewise, male sex hormones (androgens) such as testosterone, which is made by the testicles, promote growth of most prostate cancers. Drugs can be given that will block the action of these hormones or reduce the amount that is made. Side effects depend on the type of hormone treatments used. These side effects may include hot flashes, blood clots, and loss of sex drive.

Bisphosphonates are a group of drugs used to treat conditions that weaken the bones (osteoporosis). Some of these drugs, such as pamidronate (Aredia) and zoledronic acid (Zometa), have also been used to treat patients whose cancer has spread to their bones or, as in those with multiple myeloma, started there. They help reduce bone pain and slow down bone damage caused by the cancer. These drugs are more effective when x-rays show the metastatic cancer appears to be causing the bone to become thinner and weaker. They are less effective when the cancer causes the bone to become denser.

Complementary and Alternative Therapies

Complementary and alternative therapies are a diverse group of health care practices, systems, and products that are not part of usual medical treatment. They may include products such as vitamins, herbs, or dietary supplements, or procedures such as acupuncture, massage, and a host of other types of treatment. There is a great deal of interest today in complementary and alternative treatments for cancer. Many are now being studied to find out if they are truly helpful to people with cancer.

You may hear about different treatments from family, friends, and others, which may be offered as a way to treat your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit.

The American Cancer Society defines complementary medicine or methods as those that are used along with your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven not to be useful or even to be harmful, but are still promoted as “cures”. If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying, replacing, or interfering with regular cancer treatment.

Before changing your treatment or adding any of these methods, discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it’s important to talk with your doctor.

Clinical Trials

The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are 3 phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The cancer care team also looks for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patient ??? often several hundred. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.

If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

• Is there a clinical trial for which I would be eligible?
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do? Has it been used before?
• Will I know which treatment I receive?
• What is likely to happen in my case with, or without, this new treatment?
• What are my other choices and their advantages and disadvantages?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side effects be controlled?
• Will I have to be hospitalized? If so, how often and for how long?
• Will the study cost me anything? Will any of the treatment be free?
• If I am harmed as a result of the research, what treatment would I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. Based on the information you provide about your cancer type, stage, and previous treatments, this service can compile a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at http://www.cancer.gov/clinicaltrials.

It is hard to know who will develop metastatic or advanced cancer. Some cancers are more likely to spread than others. One way is to compare how closely the cancer cells resemble normal cells (called grade). The more normal the cells look, the less likely it is that the cancer will spread. Another way is related to the size of the tumor. Also, if the cancer is found to have spread to nearby lymph nodes, it is much more likely to spread to distant sites. This is sometimes discovered after surgery if lymph nodes are removed and examined under the microscope.

Even with knowing these things, doctors aren’t always sure if a person’s cancer will spread or if they already have advanced cancer. Most of the time, your doctor will look at your history and give you a physical exam. You will have some blood tests and imaging studies. Putting all this information together, your doctor can often tell if you have advanced cancer.

Below are some of the signs and symptoms of advanced cancer and ways to find it.

Signs and Symptoms

The most telling symptom is losing your energy and feeling tired (fatigued). Most people with advanced cancer have a hard time doing everyday tasks. They often need help. At some point, it gets so bad that they spend much of their time in bed. Weight loss is another sign.

Pain may go along with advanced cancer but not always. Shortness of breath is common with lung cancer.

For more about symptoms, please see the section, “Managing Physical Problems of Advanced Cancer.”

Physical Exam

Along with asking about your symptoms, your doctor can learn much from examining you. He or she may find signs of problems caused by advanced cancer. These signs might include:

• fluid in your lungs or in your abdominal cavity
• tumor lumps on your body
• an enlarged liver

Blood Tests

Certain blood tests can point to advanced cancer. Test results of liver function are often very abnormal if the cancer has invaded the liver. Your cancer might produce a substance called a tumor marker. Examples are PSA (prostate-specific antigen) if you have prostate cancer, or CEA (carcinoembryonic antigen) if you have colon cancer. The level of these substances in the blood may be very high. There are many other tumor markers for other cancers. For more information, see the American Cancer Society document “Tumor Markers.”

Imaging Tests

Chest x-ray: A chest x-ray can find tumors in your lungs or fluid in your chest.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine takes pictures of multiple slices of the part of your body that is being studied. Often after the first set of pictures is taken, you will receive an intravenous injection of a contrast agent, or dye, which helps better outline structures in your body. A second set of pictures is then taken.

CT scans can also be used to guide a biopsy needle precisely into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ??-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.

CT scans are more tedious than regular x-rays because they take longer and you usually need to lie still on a table for 15 to 30 minutes while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the equipment you lay within when the pictures are being taken.

You will need an IV (intravenous) line through which the contrast dye is injected. The injection can also cause some flushing. Some people are allergic and get hives, or rarely more serious reactions like trouble breathing and low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. You may be asked to drink 1 to 2 pints of a contrast solution. This helps outline the intestine so that it is not mistaken for tumors.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans but is used less often.

MRI scans are also very helpful in looking at the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer ????? often up to an hour. Also, you have to be placed inside tube-like equipment, which is confining and can upset people with a fear of enclosed spaces. To stay calm, try keeping your eyes closed. Thinking of pleasant, relaxing mental images has also been shown to be helpful in making the time pass quickly. You should also feel free to ask for anti-anxiety medicines if you think this will help you. Finally, if you have a strong fear of enclosed areas, you can seek out a facility that has an open MRI. Many cities have at least one MRI center that has an open MRI (there is not an enclosed tube).

The MRI machine also makes a thumping noise like a washing machine that you may find annoying. Some places provide headphones with music to block this out. Although most people have little difficulty managing the MRI experience, you should feel free to discuss any concerns you have with your doctor or nurse. While you are in the MRI you will be able to talk to the technician throughout the procedure.

Positron emission tomography (PET): PET uses a form of sugar (glucose) that contains a radioactive atom. A special camera can detect the radioactivity. Cancer cells of the body absorb high amounts of the radioactive sugar, because of their high rate of metabolism. PET is useful when your doctor thinks the cancer has spread but doesn’t know where. PET scans can be used instead of several different x-rays because it scans your whole body.

Ultrasound: Ultrasound uses sound waves to make images of internal organs. The computer displays the image on a computer screen. Ultrasound is useful for finding out if some tumors are cancer or not. This is a very easy test to take, and it uses no x-rays. You just lie on a table while someone moves a flat wand over your skin.

Radionuclide bone scan: This procedure helps show if a cancer has metastasized to bones. You will be given an intravenous injection of radioactive material called technetium diphosphonate. The injection itself is the only uncomfortable part of the entire scanning procedure. The amount of radioactivity used is low compared with the much higher doses used in radiation therapy, and this low level of radiation does not cause any side effects.

The radioactive substance is attracted to diseased bone cells throughout the entire skeleton. Areas of diseased bone are seen on the bone scan image as dense gray to black areas, called “hot spots.” These areas may suggest metastatic cancer is present, but arthritis, infection, or other bone diseases can also cause hot spots. Their pattern is usually different from the pattern caused by cancer. To distinguish among these conditions, the cancer care team may use other imaging tests or take bone biopsies. Bone scans can find metastases much earlier than regular x-rays. Not only are they useful in spotting bone metastases; they can also track how they respond to treatments.

Sometimes bone scans fail to find areas of spread to the bones. This happens most often if the metastases are osteolytic (destroying or dissolving bone). In some patients, the scan may show no radioactivity in certain areas of bone that have been totally destroyed by the cancer.

Biopsy: Often when an imaging test finds something that isn’t normal, the doctor will want be certain that it is cancer. This is usually done be taking a small piece of tissue and looking at it under the microscope. Usually this biopsy is done by putting a needle into the spot and sucking out fragments of tissue or a core of tissue. Sometimes cancer cells can be found in fluid that has built up in the chest or abdomen. These samples are then examined under the microscope. It is important that your doctor is certain that the cancer has spread and often a biopsy is the only way.

For now, the only sure way to prevent the spread or growth of a cancer is to find the cancer early enough and remove it or destroy it. The American Cancer Society recommends early detection tests for cancers of the breast, prostate, colon, and cervix. But many people do not know about or do not follow these recommendations and are more likely to have cancer found after it has already spread. And because these tests are not perfect, some cancers may spread before they can be found. There are also many cancers that cannot be found early by any of the tests that are now available.

Researchers are looking for ways to keep cancer from spreading. For example, drugs are being studied that might block the enzymes that help cancer cells break holes through the walls of blood vessels. Other drugs block the formation of new blood vessels. Some patients such as those with breast or colorectal cancer are often given drugs after surgery to kill cancer cells that might have broken away from the primary tumor.

More than half a million people will develop and die of advanced cancer each year in the United States. Over 70% of these people will be older than 65 years old. Although more than 60% of all people who get cancer will live 5 years or longer, people with advanced cancer usually live less than a year.

How Cancer Cells Spread

Metastasis is the end result of a multistep process. Cancer cells travel from the organ they develop in through the blood and/or lymphatic vessels to other parts in the body.

Step 1 is the development in a cancer of some cells that are faster growing and more likely to spread. The cancer cells in a tumor are not uniform. As the cancer grows, some of the cells that develop are more “malignant” than others. These are cells that grow faster and also tend to spread.

Step 2 is angiogenesis, where the tumor promotes the development of its own blood supply so that it can grow faster.

Step 3 is the growth of the more malignant cells that tend to spread. Normal cells that form organs such as the lungs and liver are held in place by a substance called extracellular matrix, or ECM. This is like the mortar holding bricks together to form the walls of buildings. For cancers to spread, their cells must break loose from the ECM. Cancer cells may do this by producing enzymes that break down the ECM. However, breaking loose from a tumor is only the first of many steps a cancer cell must take before spreading. Cancer cells must undergo changes that enable them to break through the walls of blood vessels or lymphatic vessels.

Step 4 is survival in the blood stream. The majority of the tumor cells entering the blood or lymph circulation are destroyed. Only the most malignant cells will survive.

Step 5 is the ability of the cells, once they have survived, to attach to distant organs or lymph nodes.

Step 6 is a key part of growth in a new environment ??? the ability of the new tumors to form new blood vessels (angiogenesis) that carry nutrients and oxygen to the growing tumor.

Step 7 is the ability of these cancer cells to grow in their new environment and avoid the body’s attempts to reject them.

Why Cancer Cells Tend to Spread to Certain Parts of the Body

The type of cancer and where it starts often determines where it will spread. Most tumor cells that have been dislodged from the original tumor are carried in the blood or lymphatic circulation until they get trapped in the next “downstream” capillary bed or lymph node(s). This explains why breast cancer often spreads to axillary (underarm) lymph nodes but rarely to lymph nodes in the groin. Likewise, the lung is a common site of metastasis for many cancers. This is because the heart pumps blood from the rest of the body through the lung’s blood vessels before sending it elsewhere. The liver is a common site of metastasis for cancer cells arising in the stomach and intestines because blood from the intestines flows into the liver.

Sometimes the patterns of spread cannot be explained by anatomy. Some cancer cells are able to find and invade specific sites. This “homing” pattern may be caused by specific substances on their surfaces that stick to cells in certain organs. In other cases, cells of some organs release hormone-like factors that actually cause cancer cells to grow faster.