Chapter 077. Approach to the Patient with Cancer (Part 1)

Harrisons Internal Medicine Chapter 77. Approach to the Patient with CancerApproach to the Patient with Cancer: Introduction The application of current treatment techniques (surgery, radiation therapy, chemotherapy, and biological therapy) results in the cure of nearly two of three patients diagnosed with cancer. Nevertheless, patients experience the diagnosis of cancer as one of the most traumatic and revolutionary events that has ever happened to them. Independent of prognosis, the diagnosis brings with it a change in a persons self-image and in his or her role in the home and workplace. The prognosis of a person who has just...
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Chapter 077. Approach to the Patient with Cancer (Part 1) Chapter 077. Approach to the Patient with Cancer (Part 1) Harrisons Internal Medicine > Chapter 77. Approach to the Patient withCancer Approach to the Patient with Cancer: Introduction The application of current treatment techniques (surgery, radiation therapy,chemotherapy, and biological therapy) results in the cure of nearly two of threepatients diagnosed with cancer. Nevertheless, patients experience the diagnosis ofcancer as one of the most traumatic and revolutionary events that has everhappened to them. Independent of prognosis, the diagnosis brings with it a changein a persons self-image and in his or her role in the home and workplace. Theprognosis of a person who has just been found to have pancreatic cancer is thesame as the prognosis of the person with aortic stenosis who develops the firstsymptoms of congestive heart failure (median survival, ~8 months). However, thepatient with heart disease may remain functional and maintain a self-image as afully intact person with just a malfunctioning part, a diseased organ (a bumticker). By contrast, the patient with pancreatic cancer has a completely alteredself-image and is viewed differently by family and anyone who knows thediagnosis. He or she is being attacked and invaded by a disease that could beanywhere in the body. Every ache or pain takes on desperate significance. Canceris an exception to the coordinated interaction among cells and organs. In general,the cells of a multicellular organism are programmed for collaboration. Manydiseases occur because the specialized cells fail to perform their assigned task.Cancer takes this malfunction one step further. Not only is there a failure of thecancer cell to maintain its specialized function, but it also strikes out on its own;the cancer cell competes to survive using natural mutability and natural selectionto seek advantage over normal cells in a recapitulation of evolution. Oneconsequence of the traitorous behavior of cancer cells is that the patient feelsbetrayed by his or her body. The cancer patient feels that he or she, and not just abody part, is diseased. The Magnitude of the Problem No nationwide cancer registry exists; therefore, the incidence of cancer isestimated on the basis of the National Cancer Institutes Surveillance,Epidemiology, and End Results (SEER) database, which tabulates cancerincidence and death figures from nine sites, accounting for about 10% of the U.S.population, and from population data from the U.S. Census Bureau. In 2007, 1.445million new cases of invasive cancer (766,860 men, 678,060 women) werediagnosed and 559,650 persons (289,550 men, 270,100 women) died from cancer.The percent distribution of new cancer cases and cancer deaths by site for men andwomen are shown in Table 77-1. Cancer incidence has been declining by about2% each year since 1992. Table 77-1 Distribution of Cancer Incidence and Deaths for 2007 Male Female Sites % Numb Sites % Numb er er Cancer Incidence Prostate 29 218,89 Breast 26 178,48 0 0 Lung 15 114,76 Lung 15 98,620 0 Colorect 10 79,130 Colorecta 11 74,630al l Bladder 7 50,040 Endometr 6 39,080 ial Lympho 4 34,200 Lympho 4 28,990ma ma Melano 4 33,910 Melanom 4 26,030ma a Kidney 4 31,590 Thyroid 4 25,480 Leukemi 3 24,800 Ovary 3 22,430a Oral 3 24,180 Kidney 3 19,600cavity Pancreas 2 18,830 Leukemia 3 19,440 All 18 136,53 All others 21 145,28others 0 0 All sites 10 776,86 All sites 10 678,06 0 0 0 0 Cancer Deaths Lung 31 89,510 Lung 26 70,880 Prostate 9 27,050 Breast 15 40,460 Colorect 9 26,000 Colorecta 10 26,180al ...