9. When cancer causes symptoms
More often than people realize and contrary to popular belief, a cancer diagnosis is not always a straightforward affair. Cancer may cause symptoms that develop gradually, over months, or suddenly, necessitating urgent medical attention. These symptoms may be caused by the primary tumor or by a cancer’s distant metastases -tumors causing a problem in another organ (this is explained later).
Indeed, cancer declares itself in many ways, and some of them can be misleading. This is a common source of frustration and angst for patients and their primary physicians alike.
Symptoms from a cancer often mimic those caused by common ailments, so doctors first think of the more common reasons for a person to exhibit a symptom, and rightly so. (Exceptions would be if there is a strong family history of cancer that should make the physician more vigilant for signs of that cancer.) It is certainly possible that a headache may be caused by a brain tumor, but it is far more likely that there is a benign cause, such as tension or migraine. Stomach pain can be a sign of stomach cancer, but it is much more likely to be caused by an ulcer. A cough can be a sign of lung cancer, but it is far more likely to be caused by the more common ailments of a cold, postnasal drip, or asthma. If symptoms persist or worsen, further tests are performed and may uncover a cancer.
Another way cancer can masquerade is if it occurs in a person who has a chronic disorder and the symptoms are similar to those caused by that ailment. For example, a person with chronic back pain from arthritis who develops more back pain in the same region would be thought, at first, to have a worsening of arthritis. If a cancer is lurking,
too, it may take time before the patient and physician realize that this pain is different and perhaps not responding to the usual remedies. If the symptoms are tolerable and the person chooses to live with them,some months may pass before further testing is performed. When thecancer is ultimately found, the patient may feel that the doctor “missed”the diagnosis earlier. But the doctor may be very skilled and diligent and treated the patient according to the likeliest situation, that the symptoms were simply a worsening of arthritis. In time, an MRI or a CT scan of the affected region would be done and reveal a tumor rather than arthritis; a biopsy would be done to diagnose cancer. It would have been impossible for the doctor to know from the outset that the new symptoms were caused by cancer.
This case illustrates the complexity of medicine and the challenges in being a physician. It also underlines the difficulty in being a patient, in conveying symptoms accurately and in monitoring (even complaining about!) a symptom that is not improving. More than any test, the patient’s words, that “something is just not right,” will lead the doctor to find the root of a medical problem. My grandmother was way ahead of her time, many years ago, when she inculcated me with this wisdom: “Listen to your patients, they will let you know what is wrong with them. They know their bodies better than anyone else.”
Another way cancer can present itself is when a metastasis, rather than the primary cancer, causes symptoms. An example would be a person who develops pain in the region of the liver. A CT scan is ordered, and it shows growths in the liver that look like cancer deposits that have spread to the liver from another location (this is much more common than primary liver cancer). Because one of the more common places for this to happen is from the colon, a colonoscopy is performed. During this procedure, a tumor is found in the colon, and biopsy reveals colon cancer. Here symptoms caused by the spread of cancer ultimately led to the identification of the primary cancer.
