In-Depth Cancer Basics
“To educate is to give power
To give power is to gain control
To gain control is to reduce fear
To reduce fear is to give hope
Hope is life’s key to survival”
What is Cancer?
Every cell in your body has a job. A colon cell lives for 4 days before it’s replaced. Skin cells live for two or three weeks. Brain cells typically last an entire lifetime.
Carcinogens like viruses, smoking, asbestos, sun exposure, and RANDOM mutations cause DNA errors during the cell division process. These mutations happen ALL the time during a person’s life. Cancer happens when the body doesn’t catch the mistake. Usually 6 mutations/division errors need to occur before a cancer cell is formed.
A single cancer cell has to divide to become 1 billion cancer cells before they are around the size of a pea, which is a 1 cm mass. That is the smallest size that can be felt (Cancer Basics). The smallest lung nodule that can be biopsied (if location is amenable) is 0.8cm.
“Cancer cells are normal cells that have lost the ability to correct their mistakes” (Natalia Colocci, MD).
Cancer cells are basically normal cells that become cyborgs: they break ALL of the rules. Unlike healthy cells, cancer cells never die, pirate blood vessels to feed the tumor, invade other spaces (Colon tumor can block the intestine) and spread to other organs through the blood and lymph system (like the subway system of the body). When they settle they start to multiply and create tumors.
A test we are starting to use is Circulating Tumor Cells (or Circulating Tumor DNA). which can tell us after treatment if a patient has cancer cells in their blood. I think this will be the future of oncology care and if the price can be reduced, would help with screenings.
There are cancer cells from a patient named Henrietta Lacks, who had a biopsy of her cervical cancer in 1950 and those cells are still being studied in labs around the world (the cells were named HeLa) but . She died in 1951 and did not give consent to be studied.
The future of cancer treatment: Biomarker Driven Therapy
A normal part of our cells tell the cell when to STOP dividing (Tumor Suppressor cells) and when to START dividing (proto oncogenes). Errors including EGFR and BRCA mutations can cause cancer from errors in the GAS and BRAKES of the cell.
Each normal cell has Proto-oncogenes that tell it to GO and divide! These include epidermal growth factor receptors (EGFR) on the cell surface. When an epidermal growth factor protein binds with the receptor, the cell divides. In cancer cells, there can be too many EGFR receptors. This defect is known when the proto-oncogene (GO mechanism) has an error and becomes an oncogene. One new cancer treatment inhibits those receptors (Tarceva, Erbitux).
Tumor Suppressor cells tell atypical cells to STOP growing and die (apoptosis). BRCA 1 +2 are tumor suppressor cells. If someone has a BRCA mutation (Breast Cancer mutation), these cells that normally repair DNA breaks are defective. Just because someone has a BRCA mutation doesn’t mean they will develop cancer, but they do have a SIGNIFICANTLY higher rate of developing cancer than someone without the mutation.
WHY DID THE CANCER DEVELOP?
There are certain risk factors that can influence the development of cancer but usually there is not a direct cause. For Example, some people smoke a few cigarettes a day and get lung cancer. Some people smoke a pack per day and never develop cancer (these patients who smoke every day and don’t get cancer have something in their immune system that is protecting them from developing cancer).
The general answer for what causes cancer is a combination between genetic/familial changes (DNA errors passed down from generation to generation) and environmental factors and we don’t know. Examples of familial genetic changes are like BRCA mutation for breast cancer: Everyone has BRCA genes. These genes normally keep cells from growing out of control and turning into cancer. But when these cells have a mutation, they aren’t able to stop the erroneous cells from turning into cancer. Individuals with a BRCA 1+2 gene mutation have a 45-87% chance of developing breast cancer.
However, only 5-10% of breast cancer cases are from familial/hereditary DNA changes.
70-80% of breast cancer cases are “sporadic,” meaning they just happen and we can’t tell you a reason.
ARE CANCER RATES RISING?
The older you are, the higher your risk of developing cancer.
Our cells aren’t as sharp and self-regulating as we age. Our population is aging… the world lifespan in 1950 was 48, 2014 lifespan was 71.5. As we have developed better treatments for heart conditions, blood pressure, and other diseases, everyone is living longer. We have more living older people, so we are going to have more people alive with cancer.
BUT WHAT ABOUT PEDIATRIC CANCER?
Yes, certain types of pediatric cancers are rising and other types are staying the same. Of all the people diagnosed with cancer, kids only make up 1% . Overall pediatric cancer rate is rising at 0.6% gradually.
WHY HAVEN’T WE CURED CANCER?
After millions of dollars in funding, donations, and research? Why haven’t we cured cancer? The answer is that cancer is not one villian to defeat. It’s over 100 different kinds of villians, and our opponent is by nature adept at living forever and can change/morph to survive. This video explains it well:
https://www.youtube.com/watch?v=h2rR77VsF5c&feature=youtu.be
Is there anything I can do to prevent myself from getting cancer?
Aromatherapy, juice cleanses, coffee enemas, alkaline water, antioxidants, clean beauty… there are promises everywhere that there are products we can buy and steps we can take to avoid getting cancer. My very first Oncology Nursing conference I went to a seminar on how to avoid environmental exposure to carcinogenic substances and I was EXCITED! I had my notebook out and was taking feverish notes about different programs you can plug your beauty products into that will tell you how “bad” they are. They then advanced to a slide referring to radon exposure and it detained how radon exposure causes cancer and it seeps into every home in America through the walls, bathroom fixtures, and the soil. Disneyland has a sign that it contains chemicals that cause cancer.…. The Safe Drinking Water and Toxic Enforcement Act, better known as Proposition 65, requires warning labels for about 900 chemicals known to cause cancer or birth defects. The sign up at Starbucks is referring to acrylamide, a substance that develops while heating foods up and roasting coffee. The concentrations were actually higher which making potato chips and the chip industry was forced to come up with a different way to make chips. As the Washington Post reported, rodents can develop cancer from acrylamide, but only when fed "rates 1,000 to 10,000 times higher than what humans consume in food."
Stress can wreak havoc on your body. If you become fixated on NOT getting cancer and are under a great deal of stress about it, your adrenal glands will make more cortisol and you will be at greater risk to get sick (immune system depression). I personally try to avoid known risk factors. I have seen perfect physical specimens (some of the healthiest people I’ve ever seen) diagnosed with and die from cancer, and some of the most unhealthiest, heavy smokers NOT get cancer. You can only do so much, so my motto is to focus on what is proven to give us the biggest bang for our buck with cancer prevention.
The World Cancer Research Fund estimates that about 20% of all cancers diagnosed in the US are related to body fat, physical inactivity, excess alcohol consumption, and/or poor nutrition, and thus could be prevented.
Get at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week (or a combination of these).
Can I eat anything or take supplements to prevent cancer: YES. Eat a diet high in vegetables, fruits, whole grains, beans, herbs, and spices, Aim to fill 2/3 of your plate with these! Favor brightly colors or strongly flavored vegetables, fruits, herbs and spices, which are often the best sources of phytochemicals. Phytochemicals help your immune system, block substances we eat, drink, and breathe from becoming carcinogens, reduce inflammation, prevent DNA damage and promote DNA repair, slow the growth rate of cancer cells, help to regulate hormones. Phytochemicals are more easily absorbed in food sources than supplements.
Does sugar feed cancer?
Short answer: no. Cancer cells are like any other cells in the body: they use energy. Sugar is energy. Every calorie you eat is converted into energy and every cell in your body uses that energy to live and work. If you give up all sugar, your normal cells, and cancer cells, will still find an energy source to allow them to grow and divide. Now, of course, you shouldn’t eat cheesecake for breakfast, lunch and dinner. Aim for a balanced diet rich is vegetables, whole grains, beans, herbs, and spices.
How is cancer diagnosed?
During preventative testing (mammograms, colonoscopies), early cancer can be detected (and sometimes treated right there, such as when polyps are found during colonoscopies). Otherwise, the symptoms of cancer can be unintentional weight loss, loss of appetite, night sweats, blood in the urine or stool (for the love talk to your doctor if you ever have any of those symptoms and encourage your loved ones to do the same). There are some cancers which have vague symptoms, such as abdominal bloating and feeling full early while eating for ovarian cancer. More research is needed for better screening tests for these cancers. Usually we use a CT scan to get a first look at a tumor. CT scans are good at looking at structures and finding tumors. PET scans light up rapidly diving cells. A radioactive isotope is injected into an IV (like sugar) and it helps light up rapidly diving cells. MRIs give even better looks at body structures and tumors.
We can stage cancer by where the tumor is, how large it is, if the lymph nodes in the area are involved, if it’s spread regionally (stage 3). If the cancer has spread to any other organs, it’s a stage 4 and considered late stage, but that doesn’t always mean a death sentence. People with stage 4 cancer can still live many years. When you look up 5 year survival rate, that tells you what percentage of people with that cancer diagnosis are alive 5 years from first finding out they have that cancer (no matter if they are still on treatment or not, only what percentage of patients with this diagnosis are alive).
When we find a tumor, a biopsy is done to confirm it’s cancer and see what kind. There are over 100 different kinds of cancer. A biopsy is always done to confirm what type of cancer it is. The biopsy also tells us what grade the cancer is, meaning how different is the cancer cell from a normal cell. If the cancer cell looks similar to a healthy cell, it’s less likely to grow and spread quickly (low grade). If the cancer cell looks very different from a normal cell, it’s high grade and more aggressive. Most cancers usually spread to the liver, lung, bone and brain. A misconception I’ve heard a few times is: if she had breast cancer and now she has a brain tumor, now she has brain cancer! If you do a tissue biopsy of the brain tumor, under a microscope it would look like mutated breast cells. She has stage 4 breast cancer (or breast cancer in her brain). There are lots of different types of tissue testing to see how aggressive the cancer is, where it originated from, and what types of treatment it will respond to (MSI, Oncotype, hormone receptor status, etc.).
How is cancer treated?
There are over 100 different types of cancer, and each cancer has 4 stages (and each stage is treated differently). There are hundreds of different treatment combinations to treat cancer. In general, cancer is treated with chemotherapy, radiation, and surgery. Newer treatments include immunotherapy. The oncologist is like the team captain and they order chemotherapy themselves. If they need to pull in other specialists, they will refer out to a surgeon or radiation oncologists, but the patient always comes back to the oncologist and ultimately follows up with the oncologist after treatment is complete.
What is chemotherapy?
Usually, people think of chemotherapy as making someone bald and vomiting all the time. We have gotten much better at treating side effects from chemotherapy, so the goal of any treatment is to have minimal side effects by using complementary medications to prevent side effects, like anti-nausea meds.
Chemotherapy is neoplastic substances that are either ingested, injected, or given intravenously to kill all rapidly dividing cells. Think… if you cut your hair, it usually grows back in a few weeks. If you scratch your mouth, it usually repairs itself in a few days. You don’t realize it, but your bone marrow is constantly pumping out new cells. Most cancer cells also grow very quickly. Chemo kills all rapidly dividing cells, including hair cells, cells in your GI tract (mouth to anus), your bone marrow cells, and (the ideal target) cancer cells. Therefore, chemotherapy works to kill cancer cells but also has some unsavory side effects on your body’s rapidly diving cells. Side effects are usually nausea/vomiting, constipation or diarrhea (or both), bone marrow suppression because blood cells are rapidly dividing, hair loss, muscle pain, and fatigue. The bone marrow suppression is the most dangerous, because if someone catches the common cold or something similar, their immune system is impaired and it can become deadly. Never visit someone who is going through chemo when you are sick or have been exposed to illness. We use medications to manage and prevent the side effects. The bone marrow suppression is usually the side effect that can be dose-limiting meaning treatment may need to be delayed or skipped if their blood counts drop too low (or patients can need blood transfusions of platelets or red blood cells or injections to make their bone marrow make more red blood cells or white blood cells, AKA colony stimulating factor injections). Before each chemotherapy treatment, doctors check in to make sure the side effects are tolerable and their organ function and bone marrow is functioning properly. Chemotherapy is present in blood levels for about 48-72 hours after infusion and if you test someone’s bodily fluids during that time, there will be traces of chemo in it. Different types of chemo target killing cancer cells during all of cell division or specific phases of cell division.
Chemotherapy can be given before surgery to shrink a tumor to make it easier to remove, after surgery to kill any microscopic cancer cells left over, or to shrink the tumor indefinitely, also known as palliative. The goal of treatment can be divided into curative versus palliative. Curative means the goal of treatment has a definite timeline and the goal at the end of treatment is for the patient to be “cancer free.” Once treatment is complete, if there are no tumors that could be seen on any scans, we would say “no evidence of disease” and at that point, they are considered to be in remission. Usually, after 5 years with no evidence of disease, then we can truly say a patient has been cured. If someone has stage 4 cancer or cancer that was in remission and has come back, the goal of treatment is usually palliative, meaning the goal is to shrink the tumors and prevent them from growing larger. This is my biggest bone to pick with oncology care in America that I have experienced: Doctors don’t want patient’s to lose hope or become more upset, so they use terms like “we have another treatment we can try” or “the chemo is no longer working so we can change to a different kind.” Patients should really understand if the treatment they are offered is palliative and if so, what is the goal of this treatment? To add months onto survival time? If so, maybe it’s not worth it to that person. Usually with palliative treatment, they keep receiving the chemo at regular intervals until there is proof via a scan the treatment is no longer working.
What do my labs mean?
A CBC (complete blood count) and CMP (complete metabolic count) and usually drawn before each cancer treatment and to follow up after treatment routinely, as well as for everyone’s annual physical, so everyone has something to learn from knowing about CBC and CMP blood tests.
A CBC looks at White blood count, red blood count and platelets. White blood cells fight infection, Red blood cells deliver oxygen to your tissues, platelets help you stop bleeding once you start. When you have a low white count, you are susceptible to infection. Part of the WBC value measures neutrophils. The absolute neutrophil count goes below 500, there is a very high risk of developing infection, and not just from being exposed to someone sick. A high white blood count can mean infection. We usually look a hemoglobin and give blood transfusions when the hemoglobin goes below 8. Symptoms of low hemoglobin are tiredness, shortness of breath and dizziness. Platelets are what help your blood clot after you are cut. When you have low platelets, you can get injured and your body will have a hard time stopping bleeding. Patients can get nosebleeds and need to be really careful using knives or even flossing. Having dental work while platelets are low can cause excessive bleeding, so we recommend patients get their teeth cleaned before starting treatment if possible.
The CMP looks at organ function, most notable the kidney and liver function. The creatinine and Blood Urea Nitrogen measure kidney function. If those numbers are high, the kidneys may not be able to filter out chemo. Hydration is super important while getting chemo, to help your kidneys have plenty of fluids to help flush out the chemo. If the ALT or AST are high, those mean the liver is not processing properly.
Tumor markers can be helpful to guide us if the cancer is particularly active, but do not have a ratio of 1:1 with tumor burden Tumor markers include CA-125 for ovarian cancer, CEA for colon cancer. LDH is another test we will use and if that number is very high, it can indicate active cancer. I want to reiterate that these are non-diagnostic, but (for example) during an annual follow up, if someone who finished treatment for ovarian cancer and their last CA-125 was 5 and now, 6 months later it is 200, this may raise a red flag that has the doctor possibly wanting to do a CT scan to see if there is some active disease.
What is surgery for cancer?
In general, if surgery is offered for cancer treatment, that is a really good thing (unless the tumor would cause serious problems being left there like seizures in brain or bowel obstruction). That means the cancer is early stage (1-3) and the doctor thinks they have a chance at removing all of the cancer cells we can see (aka tumor). There is a cliché scene where the surgeon comes out and says: “we got it all.” PEACH EXAMPLE. We want negative margins, meaning, no cancer cells on the border of where the surgeon cut. We don’t want to cut into cancer. Depending on the stage, usually additional treatment is needed to kill any left over cancer cells that we cannot see. I usually liken this to pulling weeds. You have the weed and the root, but somehow, that same weed grows back in the same spot or somewhere nearby. That’s because microscopic cells were left and they need to have systemic treatment to kill them off.
What is radiation:
Radiation is a very expensive, giant machine that delivers radioactive energy to the area around where the cancer was to kill off remaining cancer cells that we cannot see. Sometimes it is used before surgery to shrink the tumor, to make it easier to remove surgically. Other times it can be used to help a tumor shrink in someone who has advanced cancer and symptoms, like pain. Usually the goal of radiation is “local control.” Typically, radiation treatments themselves are a few minutes while laying perfectly still, kind of like x-rays. You don’t feel a thing. The first step is to meet with the radiation oncologist. Then, they perform CT scans to plot out the patient’s exact anatomy and deliver radiation only to the tumor site and a very small margin around it. The overall appointment can last 20-30 minutes because you have to get in a gown, lay in the exact same position every time and they sometimes make physical structures to help you do so and get set up in the exact right position. The treatment itself is super quick but all the other stuff takes a little while. Typical radiation treatments are every weekday, Monday to Friday, for 5 weeks. Side effects can be skin burn, similar to a sunburn that develops and depending on the site can have other symptoms such as diarrhea if the colon gets any radiation, etc. There are other treatments they can do with radiation, but that is in general.
What is immunotherapy?
Immunotherapy uses your own immune system to detect and kill cancer cells. This was your immune systems job anyway, but it revs up your immune system to do their job better and outsmart the cancer cells. Immunotherapy helps flag abnormal proteins in cancer cells so the immune system can come and destroy. When the body’s immune system detects something harmful, it produces antibodies. Antibodies are proteins that fight infection Monoclonal antibodies are a specific type of therapy made in a laboratory. The side effects are different than chemo, but there are still side effects. You can still have nausea/vomiting, rash, colitis/diarrhea, etc.
Is cancer contagious:
In a word: not usually. We don’t know what causes most cancers, but as we have discussed earlier, hereditary risk factors and lifestyle risk factors can contribute to someone developing cancer. However, there are some types of cancer that are directly caused by infection, like cervical cancer. Almost all cervical cancers are caused by HPV. HPV is transmitted sexually. You can “catch” HPV from a partner. In general, the body’s immune system kills the HPV infection, but not every time. Not all people who have HPV develop cancer, but almost all people who have cervical cancer have HPV. The Gardasil vaccine was developed to help treat the most aggressive HPV strains.
Testing for Cancer:
This is such a drag. I hate going to the doctor. I don’t like getting preventative testing and it’s only going to get worse as I get older. But I’d much rather have one day of testing than cancer. If you do regular Pap exams, they can catch HPV infections causing abnormal cells early and treat them. Colonoscopies are recommended for anyone over 50 and during the colonoscopy, if they find any polyps, they will remove them and thus they can find and treat early stage colon cancer all in one shot! Same with annual mammograms. This isn’t meant to shame anyone into getting testing, but one of my most favorite patients once had said she was “the postergirl” for not getting a colonoscopy.” She and her best friend decided they were never going to get them. During her time getting treatment, she decided to try to tell as many people as she could to get their screening colonoscopies. She ended up passing away before she ever met her grandkids. As unpleasant as preventative testing is, it is 1000 times quicker, less painful, and better than getting a cancer diagnosis and going through treatment, Not to mention cheaper. Make an appointment with your PCP to make sure you are up to date on your preventative testing.
What is palliative Care?
Aggressive symptom management for someone receiving cancer treatment. They can help with symptoms like nausea, diarrhea, constipation, pain, as well as help someone discuss their goals of care, advanced healthcare planning, etc.
What is hospice?
While someone is getting treatment for cancer, quality of life is something considered, but the top priority is killing the cancer cells. We always do our best to manage side effects from treatment and the cancer itself. When the goal is no longer to kill the cancer cells, care can shift to focusing on quality of life purely. This means no more testing, no more cancer treatment, but only medications and interventions that will help someone feel better. All of their care is transitioned to hospice, with visiting nurses and staff coming to someone’s home. You can be on hospice at home, or you can be in an inpatient facility. If someone is on hospice and their symptoms are out of control (lots of pain for example), they can be admitted to the hospital to get symptoms under control. These were the patients I would work with in San Diego and Orange county.
What is the end of life care act?
https://coalitionccc.org/tools-resources/end-of-life-option-act/
DDMP- cecanol