ACADEMY PUBLIC POLICIES

“Was the cancer caught in time?” This is one of the first and most important questions patients ask when they are diagnosed with cancer. With this question, they are asking if their cancer was detected before it had a chance to spread to other parts of the body (a process called “metastasis”).

It is commonly thought that if a cancer has not metastasized, then it is curable, but if it has metastasized, then it is not curable. For many cancers, this is true, but there are many exceptions, so it is important to avoid generalizations. For example, if lung cancer has spread to the liver or brain, then it is rarely curable (note that I did not say “never curable” because there are people who have beaten advanced lung cancer).

In contrast, testicular cancer that has spread to the same locations is potentially curable, as evidenced by the superhuman cyclist Lance Armstrong, who overcame testicular cancer that spread to his brain.

Another common reason to ask if the cancer was caught early enough is that many people have fears about chemotherapy and hope that if their cancer is contained, then locally directed therapies, such as surgery or radiation, will be all that is required for them to beat their cancer.

This fear is understandable because chemotherapy drugs are strong medicines that can cause serious side effects. But extreme aversions to chemotherapy need to be dispelled because these medicines save lives.

And chemotherapy administration today causes far fewer side effects than in the past. Many cancer patients today can live reasonably normal lives, even work and enjoy leisure activities, while undergoing chemotherapy treatments. I am always amazed at how many patients in our outpatient infusion room are eating away while chemotherapy drips into their arm through an intravenous line. Many have a bagel in one hand, an IV pole in the other, and are scooting around talking to others to pass the time. This could not have happened twenty years ago, when nausea and vomiting wracked patients and kept them in their hospital beds.

To describe how cancer spreads, I need to introduce some medical terms. The organ where a cancer originates is called the “primary” site. The breast is the primary site in breast cancer, the prostate the primary site for prostate tumors, and so on. For example, a breast cancer begins in a breast cell that becomes transformed into a cancer cell and multiplies into a tumor that becomes detectable. This same process is repeated during the birth of every cancer. The main primary sites of origin for cancers affecting men and women we speak later.

The locations in the body where a cancer spreads are called “metastatic” or secondary sites. Metastatic sites develop when individual cancer cells leave the primary tumor mass and travel to another location in the body, where they grow into tumors. Although a cancer can spread to virtually any part of the body, each type is associated with certain “preferred” distant sites. Knowledge of these sites guides the initial assessment of the extent of disease (called the “staging workup”). For example, a patient with newly diagnosed lung cancer will undergo: a CT scan of the chest to search for spread of the disease to other parts of the lungs as well as lymph nodes in the chest; a CT scan of the abdomen to search for metastases in the liver and adrenal glands; an MRI of the brain to search for cancer there; and either a bone scan or a PET scan to detect any bony metastases (a PET scan is also useful for detecting cancer in other parts of the body, but not the brain). It is important to understand that wherever metastases are found, they are still composed of the same cancer cells as those found in the primary cancer. An analogy used by one of my colleagues is that an Italian who moves from Italy to the United States is still an Italian! 

Another example would be that of the patient with ovarian cancer I described earlier. Although cancerous growths were found in her lungs, A. did not have lung cancer. Instead, she had ovarian cancer that had metastasized to the lungs. The same ovarian cancer cells that were detected when her ovarian tumor was biopsied would be found in her lung tumors if they had been biopsied. For any cancer, this principle is true.

Prostate cancer that has spread to the bones is not “bone cancer” but still prostate cancer, now also growing in the bones; pancreatic cancer that has spread to the liver is not “liver cancer” but the same pancreatic cancer cells that have now traveled to the liver.

One colleague mine recently cared for a thirty-five-year-old man who came to our hospital emergency room complaining of severe back pain. M. put off coming to the hospital because he was frightened that he would be told he had cancer, and so he delayed seeing a doctor. He worked in construction and kept blaming his symptoms on his work. By the time M. came to the hospital, he had been suffering for months, was in excruciating pain, and was having great difficulty moving his arms, which had become numb.

On physical examination, M. was found to have a large mass replacing his testicle. CT scans of his spine showed a tumor pressing on his spinal cord, which explained the pain, arm weakness, and numbness he was experiencing. CT scans of the rest of his body showed widespread tumors throughout his lungs and in the lymph nodes of his abdomen and pelvis. The testicular mass was removed in surgery and revealed testicular cancer. M. asked him if he needed a biopsy of the other tumors,  and he told him he did not. From knowing that testicular cancer spreads by way of lymph nodes in the abdomen to the lungs and other organs, he concluded that the presentation, or entire picture, of his condition was compatible with all the masses being derived from the original cancer in his testicle. The same cells would be found in the other tumors. No further biopsies were needed. M. received four months of strong chemotherapy treatments, and his cancer went into remission. Additional surgery was eventually needed, but the cancer is, we hope, cured.