Breast Cancer
Breast cancer is second only to lung cancer in its rate of occurrence in women. There are about 150,000 to 175,000 cases yearly and about 45,000 deaths. The rate increases with age; a woman who lives to age 85 has about a 1 in 9 chance of developing breast cancer. Overall the cumulative risk of developing breast cancer is 10.2%; the risk of dying from the disease is about 3.6%. Much of the risk is after age 75.
There are several different kinds of tumors, some slow-growing, some more rapidly growing. Family history (first degree relatives) is a risk factor. Other possible risk factors include early menarche, late first childbirth (first child after 30), late menopause, and a diet high in fat and alcohol.
Recommendations for detection: a breast self-exam monthly from age 20 (more than 80% of breast cancers are found as a lump detected by the patient herself), breast exams by a physician at least every three years between the ages of 20 and 40, a yearly exam after age 40, and a baseline mammogram by age 40. The American Cancer Society recommends mammograms every two to three years during the 40's and yearly after age 50. This improves early detection and saves lives. Yearly mammograms after 50 reduce the risk of death from breast cancer 30-50%. Most breast lumps are not malignant--80% of those biopsied are benign.
Survival rates in patients treated with mastectomy compared with those treated with breast-conserving surgery plus radiotherapy appear to be identical, at least for the first 10 years. The choice of treatment depends primarily upon patient preference. A lymph node dissection or node sampling can be performed as part of a modified radical mastectomy or as a separate axillary incision using breast-conserving surgery. Information from lymph nodes provides the best means to predict disease-free condition and overall survival chance. The 10 year disease-free survival rate exceeds 70% for node-negative patients and is about 25% for node-positive patients. Aditional chemotherapy or endocrine therapy following primary tamoxifen therapy increases survival rates in women over 50 during the first five years following diagnosis.
Breast cancer occurs in men at 1% of the frequency seen in women.
Cervical Cancer
Cervical cancer is the second most common malignancy of the female reproductive tract. The Pap test can detect 90% or more of early cervical neoplasia (pre-invasive changes in cervical cells) and its use has reduced deaths from cervical cancer by more than 50%. Cervical cancer could be eliminated as a cause of death in all women if they had annual Pap tests (beginning no later than age 20); however, fewer than 40% of women do.
Most risk factors for cervical neoplasia are related to sexual activity. The seually active are at higher risk; cervical neoplasia is virtually unknown among nuns. Women who are sexually active early (mid-teens or earlier) and those with three or more sexual partners before the age of 35 (or with sexual partners with three or more partners) are at increased risk. Recently several subtypes of the human papilloma virus have been implicated as causative in cervical neoplasia. Genital herpes infection is also a risk factor.
If lesions are localized and pre-invasive, modern surgical techniques including cryosurgery, laser surgery, or the loop electrosurgical excision procedure (LEEP) can remove or destroy abnormal cells and arrest further development toward cancer without affecting future childbearing potential. Other therapies are available depending upon the nature and stage of the tumor and the patient's desire to remain reproductive.
Uterine (mainly endometrial) Cancer:
More than 99% of the cancers of the uterus are endometrial. Endometrial cancer is most common in postmenopausal women with peak incidence between 50 and 60. The cardinal symptom is inappropriate uterine bleeding. Hormone replacement therapy using only estrogen increases the risk, but adding a progestin to that therapy reduces the risk below that of women who are post-menopausal with no hormone therapy.
Treatment varies, depending upon the stage of tumor development, from surgery (hysterectomy) to various hormonal and chemotherapies. The overall five year survival rate is 63%; if the tumor has not invaded the muscle and not spread from its original location, that survival rate is 70 to 89%.
Ovarian Cancer
Ovarian cancer is relatively rare, most commonly occurring in women in their fifties. Since it usually remains undetected until it enlarges enough to cause symptoms, early detection is difficult; in 70 to 80% of patients, the disease is not diagnosed until it has become extensive within or beyond the pelvis. Any enlargement of the ovary in a postmenopausal woman should signify a malignancy that requires prompt surgical excision.
The earliest symptoms are vague lower abdominal discomfort and mild digestive complaints. The overall 5-yr. survival rate without evidence of recurrence is 15 to 45%.
Prostate Cancer
Rates of prostate cancer are increasing. It is the most common cancer in men, second to lung cancer as cause of death. There are about 222,000 cases per year (1991) and 34,000 deaths. Prostate cancer is relatively rare in men younger than 40; it accounts for a significant number of malignancies in men older than 50, and the incidence increases with each decade of life. The cancer is generally slowly progressive and may cause no symptoms early. Later, symptoms of bladder outlet obstruction may appear. Metastases to the skeletal system (which are common) may cause bone pain.
Since the early cancer is usually without symptoms, early detection is important. Yearly digital rectal exams in men over 40 are recommended. Tests for prostate specific antigen (PSA) are a way to screen for the presence of the cancer, as well as to monitor cancer progression and response to therapy.
Treatment varies with the stage of the cancer and the degree to which metastasis has occurred. When the cancer is localized and treatment is by surgery or radiation therapy, ten-year cure rates approach 65%.
Testicular Cancer
Testicular tumors are the most common malignancies in men younger than 30. Although relatively rare, rates have tripled since 1972. There are about 3000 cases diagnosed per year. The rate is highest in young white men; it is the most common cancer in the 29 to 35 year old group. Cryptorchid testes are variously reported as 2.5 to 20 times as likely to be affected by malignancy than descended testes, even if the cryptorchid testis is brought down surgically. Most testicular cancers arise from primordial germ cells, the least malignant being a seminoma.
The usual presenting sign is a scrotal mass increasing progressively in size and sometimes associated with pain. Treatment involves removal of the affected testis and examination of the appropriate lymph nodes. (Testis prostheses are available to replace the testis in the scrotum for cosmetic purposes.) Prognosis depends upon the type and extent of the malignancy. Five year survival rates greater than 80% are seen with seminomas localized to the testis or even metastatic to the body cavity. Five year survival rates for the rarer highly malignant types are poor.
Men are less likely to get regular medical checkups than women and often delay medical advice. In 88% of patients with testicular cancer the tumor has already metastasized by the time it is diagnosed. Beginning no later than age 20 men should do regular monthly examinations of the testes and not delay seeking medical help if any lumps, enlargements, or changes in consistency of the testes are found.
Trends in Cancer Mortality, 1973-1992 (% change in death rate):
(modified from text written by Dr. Nancy Parker; last revised 6/01 by Dr. Christina Wilson)