- Difficulty/pain on urination
- Interrupted or weak flow of urine
- Pain in lower back, hips or thighs
- Dimpling/puckering of skin (like orange peel)
- Changes to either or both nipples, changes in size or shape of breast
- Lumps in breast tissue or axilla, pain in one or both breasts or axillae
- Inflammation, erythema, eczema to breast
A study has found if people adhered to the recommended 5 portions of fruit and vegetables each day and reduced their daily intake of salt to 3.5g as well as their saturated fat intake to 3% of their daily energy intake, this could prevent around 33,000 deaths each year. It was calculated that 20,800 coronoary artery disease deaths, 5,876 stroke deaths, amd 6,481 cancer deaths could be prevented each year by following such guidance. Around 12,500 deaths would be in the 75 years and under category.
Scarborough P et al (2010) Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality Journal of Epidemiology and Community Health. Doi:10.1136/jech.2010.114520
About 35% of patients with breast cancer will develop metastases. 80% of these will be in the bone, 60-70% in the lung, 50% in the liver and 10-20% in the brain.
With metastases in the bone, osteoclasts (dismantle and remove damaged bone) become overactive which means more bone is broken down than replaced. Symptoms of this include pain near the affected area (this can worsen at night or at rest), hypercalaemia, fractures. Treatment for bone metastases can involve radiotherapy, surgery or biophosphate therapy which decreases the number of osteoclasts (and also their function), to allow new bone to be produced.
Frequently breast cancer metastasises first into the lung. This may present as shortness of breath, pain, or a dry cough. Other patients may be completely asymptomatic, and therefore a chest x-ray may be required to show the metastasis. A biopsy may be taken to ensure correct diagnosis.
Treatment is determined by the presence of other metastases, the patient’s health status and previous treatment history. Options include chemotherapy, hormone therapy and targeted therapy. Surgery is generally not an option because of the frequent distribution of the metastases, but may be considered if there are solitary tumours. Sometimes vena cava obstruction can occur due to lymph nodes or tumour putting pressure on the superior vena cava. This can cause stridor, faical swelling or dilation of major superior veins. This requires urgent assessment and treatment. Radiotherapy and steroids may be prescribed to reduce the obstruction caused by the swelling, occasionally a stent may be required. Pleural effusions are also a symptom of lung metastases, these need to be drained if large.
Liver metastases however, may present as bloating, nausea, ascites, abdominal pain, weight loss, back pain, jaundice or abnormal liver function tests. Liver metastases are generally diagnosed through liver function tests, CT scans, and ultrasound scans. A liver biopsy may be required if there is insufficient evidence of levels of oestrogen or human epidermal growth fact receptor-2 (HER-2). Liver metastases are generally treated with chemotherapy, hormone therapy or targeted therapies. Surgery is generally not employed because of the multifocal nature of liver metastases. Occasionally selective radiotherapy may be used or cryoablation.
Systemic treatments for metastatic breast cancer are generally either chemotherapy or hormone treatments.
Because the side effects of chemotherapy can be very severe (nausea, vomiting, hair loss, diarrhoea, neutropenia) the treatment needs to be finely balanced to enable maximum quality of life and effectiveness. These drugs may include: docetaxel, cyclophosphamide, paclitaxel, gemcitabine, epirubicin, doxorubicin (all IV) or oral drugs: capecitabine or vinorelbine.
Most breast cancers are sensitive to hormones; metastatic breast cancer that is oestrogen receptor positive and not immediately life-threatening is suitable for hormone therapy.
Tamoxifen is an anti-oestrogen which blocks the action of oestrogen in the tumour cells; this is suitable for women who are pre or post-menopause. Aromatase inhibitors are only licensed for post-menopausal women. Goserelin implants may be administered to reduce circulating oestrogen, this can also be achieved by surgical ovarian ablation or radiotherapy. This is generally a successful and well-tolerated therapy, although there are side effects including vaginal dryness, hot flushes, weight gain and problems with body image.
A European study has found that 10% of cancers in men and 3% of cancers in women were attributable at least in part to the consumption of alcohol. These were predominantly aerodigestive tract, liver and colorectal cancers, and in women, breast cancer. This study has led to discussion on reducing the recommended upper limit of alcohol consumption to 12g for women and 24g for men.
Schütze M. et al (2011) Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study British Medical Journal doi:10.0016/bmj.d1584
A study by University of California, San Francisco and published in the Cancer Research journal has found that men with localised prostate cancer who walk briskly for three or more hours per week can halve the rate at which the cancer grows and metastasises. Men who exercised more had fewer instances of bone mets, disease recurrence and death (although those with healthier lifestyles tended also not to smoke and were often younger).
An American study has found that consumption of 3 or more units of spirits per day is associated with pancreatic cancer mortality in non-smokers.
Gapstur, SM et al (2011) Association of alcohol intake with pancreatic cancer mortality in never smokers Archives of Internal Medicine. 171, 5, 444-451.
Cancer of the oesophagus can be a particularly distressing condition as it may severely affect the patient’s ability to swallow therefore impeding their eating and drinking. This is compounded by the fact that the survival rate for the past five years remains low at around 5% (unchanged for about 20 years). This type of cancer is most common in men in their 60s (perhaps due in part to lifestyle factors, including alcohol intake, tobacco use and occupational risks).
The oesophagus is about 10 inches long and joins the pharynx to the stomach and is situated behind the trachea. It consists of several layers; the outer layer is a membrane of connective tissue, inside this is the muscle layer which helps by peristaltic action to move contents down into the stomach. Within this there are layers of mucus which help to lubricate the food to ensure it moves smoothly.
Adenocarcinoma is the most common type of oesophageal cancer, it is connected to acid reflux and obesity and generally affects the lower 2/3 of the oesophagus. If acid reflux persists it can lead to squamous cells being replaced with glandular cells (a condition known as Barrett’s oesophagus) which is a risk factor for later developing oesophageal cancer.
Squamous cell carcinoma affects the top third of the oesophagus, and it is this type of cancer which is linked with tobacco use and excessive alcohol consumption.
Oesophageal cancer generally presents as intermittent dysphagia. The dysphagia will develop with time. Patients may regurgitate food from their oesophagus, this should not be confused with the vomit of stomach contents. Coughing up copious amounts of saliva is common in the mornings as it has had chance to build up overnight.
Patients may find they are losing weight and may need to adapt their diet to include softer, moister foods. In later stages liquids only may be tolerated.
Oesophageal cancer is generally diagnosed after an endoscopy where a biopsy is also taken of any lesions found. A CT scan of the chest and pelvis may then be taken. This is to check if there has been metastasis; key areas for this are lung, liver, stomach and abdominal cavity.
Treatment is planned around information gained from scans, history taking and biopsies to determine the size of the tumour, tumour type and metastasis.
There are several investigations that may be carried out:
- Endoscopic ultrasound to assess how far the cancer has spread into the oesophageal wall
- CT scan – this will show up metastasis and lymph node enlargements
- Positron emission tomography scan wherein the patient is given an injection of a radioactive substance (fludeoxyglucose F18) that is absorbed by fast-dividing cancer cells
- Cardiopulmonary exercise test – this is to assess a patient’s risk under general anaesthetic
- Laparoscopy – requires a general anaesthetic, an interval inspection of the abdominal cavity
Unless there has been metastasis, surgery will be offered. If there has been metastatic spread the patient will be referred for palliative care. In this case no further tests are necessary.
The only cure of oesophageal cancer is through surgery. However, 70-80% of oesophageal cancers return after surgery. The other options, if either the patient is unsuitable for surgery or if the cancer has metastasised are chemotherapy, radiotherapy and palliative care.
Preoperative chemotherapy may be required if the tumour has progressed past two stages, this will be to shrink the tumour; chemotherapy may be scheduled for three three-week cycles before surgery. Chemotherapy is often continued after surgery as well to reduce the risk of metastasis.
The surgery itself is a major intervention and can take around eight hours. The affected part of the oesophagus is removed with up to half of the stomach. The part of the stomach that is removed is formed into a tube and used to replace the diseased part of the oesophagus.
Post-surgery the patient will be monitored for at least 24 hours in ITU with particular concern for respiratory insufficiency and also sepsis as a result of anastomatic leak. The patient will be NMB for about a week to allow healing. Fluids are administered through a central line, and nutrition through a jejunostomy tube (which stays in place for two weeks post surgery). A nasogastric tube will also be inserted to allow release of gas or fluid from the stomach. After about a week after surgery the patient may be encouraged to drink and begin eating a soft diet. The swallow may be strange at first but will improve and become normal in time.
It may take up to a year for a patient to recover after oesophageal surgery – acid reflux may be a problem as the cardiac valve is removed during surgery. Patients may find extra pillows at night may help, and not eating for an hour before bed. Diet will be modified as the stomach is smaller so the same volume of food may need to be distributed more evenly throughout the day. Patients might not get hunger sensations any more which can make the need to eat little and often more difficult.
Recurrence of the cancer is common. Most patients will experience this. Any dysphagia after surgery needs to be discussed. It might simply be over-granulation of the anastomosis which can constrict; if this is the case, a balloon dilation of the oesophagus may be necessary (sometimes more than once). It is important to remember that the survival rate for oesophageal cancer is low and that recurrence is common.
According to researchers from Kings College London, men with prostate cancer are at an increased risks of VTE (venous thromboembolism); this is further increased in patients receiving endcrine therapy – Lancet Oncology Online
In 2003 studies were carried out which found that there were at least 100,000 people in the UK who were living with some type of lymphoedema, although this is a conservative estimate, and there could well be 200,00 Britons with lymphoedema (Moffatt 2003).
The lymphatic system maintains homeostasis by transporting interstitial fluid which contains protein, waste products and water back into the blood supply (Keen 2008). If this system fails, or is impaired, protein and fluid can accumulate in the tissues, attracting more water by osmosis which then results in a clearly visible swelling. This is known as lymphoedema (Huit 2000). A sign of lymphoedema is when there is an inability to pinch up a skin fold at the base of the second toe – this is known as Stemmer’s sign (Keen 2008). Oedema ‘pits’ when pressed, and after a few seconds the pit will disappear as the fluid returns (Nigam 2008).
Primary oedema is caused by filiaritic infection caused by mosquito bites (more prevalent in the developing world), congenital conditions such as Milroy’s disease (MacLaren 2001). Idiopathic lymphoedema is thought to occur when there is an underdevelopment of lymph vessels (King 2006).
The most common cause of lymphoedema in the UK is due to cancer treatment such as surgery or radiotherapy which cause damage to lymph nodes or removes them completely (MacLaren 2001). This is known as secondary lymphoedema, it can also be caused by trauma, inflammation (including inflammatory arthritis), or infection such as bacterial cellulitis, tuberculosis or filarial infections (Keen 2008).
Common causes of oedema are pregnancy, immobility, varicose veins and cardiac failure. All of these can contribute to the impairment of the lymph vessels’ ability to transport interstitial fluid back to the blood. Cardiac failure can result in pooling of venous stasis, pooling in the legs, which then puts pressure on the venous system, this can lead to pulmonary oedema (Nigam 2008).
Lymphoedema is not a condition that can be cured, but it can be controlled, and through treatment patients can improve their mobility, decrease the impact inflammatory episodes have on their lives, and enhance their quality of life (Huit 2000). If treatment is not initiated, the condition will gradually become worse. After time, as a result of the accumulation of the excess interstitial fluid, fat and fibrous deposits appear (King 2006). The tissue hardens and the oedema no longer pits; in such cases hyperkeratosis is common (excessive growth of skin to form scaly, horny layers), as is papillomatosis (preponderance or wart growths), and lymphorrhoea (leakage of lymph fluid) (Keen 2008), in some cases if oedema continues, massive oedema known as elephantiasis can develop as the lymph vessels become almost completely blocked, ulcers can also develop which are difficult to heal (Nigam 2008). Because the lymph fluid is protein rich, bacterial and fungal infections are common, which increases the risk of acute exacerbations (Huit 2000). Cellulitis can occur during an acute inflammatory episode and should be treated with broad-spectrum antibiotics (King 2006).
Accurate diagnosis, treatment and patient education of lymphoedema is essential if the best outcomes are to be achieved (Huit 2000). It is also important to diagnose the cause of lymphoedema in order to rule out other causes such as cardiac failure, hypertension, lipoedema, protein deficiency, DVT, or immobility. Defining the cause will ensure the most effective treatment and therefore the best outcome. Clinical presentation, previous medical history, and the results of investigations are all invaluable in determining the cause (King 2006).
Treatment (not cure) is aimed at reducing the oedema and encouraging improved lymph fluid flow (King 2006). There are several principles in the treatment and management of lymphoedema: skincare, compression, exercise, and lymphatic drainage (King 2006). From these four points, it is clear to see how essential patient education is, and how patients themselves can ensure the effectiveness of the treatment prescribed. As with all care planning, the patient should be involved in decision-making and should therefore to be able to give informed consent to proposed treatments.
It is likely that for treatment to be effective, the patient will need to make some lifestyle changes, such as increasing the level of activity and exercise taken, making changes to diet by reducing the intake of salt, and losing weight. Also patients may need to develop new habits such as elevating the affected limb(s) to aid venous return, (oedema responds to gravity and therefore if the affected limb is elevated, this assists in the drainage of the fluid back into the blood supply (Nigam 2008)), taking prescribed medication regularly, and adopt the use of compression garments (Nigam 2008). Because this may mean significant changes to a person’s lifestyle, it is particularly helpful if information can be written down for the patient in order for them to refer back to it in the future (Honner 2009).
Good hygiene and skincare is vital for people living with lymphoedema; the aim is for the skin to be kept supple, healthy and hydrated. Even tiny breaks in the skin can lead to infection (Huit 2000). Soap should be avoided as it removes the natural oils that exist to protect the skin, making it more fragile and prone to breaking. Therefore emollients should be used instead such as aqueous cream. Skin should be patted dry, and care must be taken when moisturising that products are not rubbed into the skin, but rather smoothed over the skin in a downward direction (the direction of the hair) this reduces the risk of folliculitis (Penzer 2003). Skin should be inspected daily for any signs of inflammation discolouration or breaks in the skin, as these could signal an inflammatory episode (King 2006). Patients should also be advised to take care of their affected limbs to reduce the risk of injury to them, wearing footwear at all times, or gloves when gardening or washing up, and using insect repellents and sun block adequately (King 2006).
Compression garments or bandaging can be applied to provide a graduated compression to aid vessels transporting the lymph fluid back into the blood supply, it can also prevent the oedema occurring (Huit 2000). In patients with mild oedema where the shape of the limb has not been distorted and with no contraindication (such as arterial disease, cardiac failure, VTE, or allergies), compression garments can be applied immediately with great effect. Patients need to be assessed and measured for their suitability and sizing for compression garments or bandaging (King 2006). Such garments need to be worn daily if they are to achieve their purpose. Again, this is why patient engagement is essential; without concordance most lymphoedema treatments will fail. For patients with more significant oedema, a period of intensive treatment with compression bandages may be required to reduce the oedema and develop a normal shaped limb in order to fit with compression garments. All of this needs do be done and prescribed by an adequately trained practitioner (King 2006).
Exercise is a good way of decreasing oedema, however, because the oedema itself can be a reason for limited mobility any exercise plans should be tailored for the patient’s needs and abilities (Woods 2004); if compression garments have been prescribed, they will need to be worn during exercise (King 2006). Exercise should be moderate, introducing new exercises gradually and not overdoing it. Low impact exercise such as cycling, swimming and walking are advised (MacLaren 2001).
Lymphatic drainage massage works by promoting the removal of interstitial fluid away from the oedematous areas. It should only be performed by a competent [practitioner as the technique is substantially different from regular massage techniques (Huit 2000). This is a particularly good form of treatment for those patients who are unable to tolerate compression treatments for whatever reason. Again patient involvement is vital – patients can be taught to perform this technique on themselves, which can prove effective (King 2006).
The management of lymphoedema can be difficult, there are many factors to consider, causes, contraindications to treatment, patient concordance, education and lifestyle. The more involved the patient is in their treatment, the more likely it is to be effective. Lymphoedema is often overlooked, but if poorly managed can have a seriously negative impact on a person’s lifestyle, body image, and outlook. Therefore it is imperative that lymphoedema is swiftly diagnosed, treatment determined and initiated to minimise distress and inconvenience to the patient (King 2006).
- Honner, A. (2009) The information needs of patients with therapy-related lymphoedema Cancer Nursing Practice. 8, 7, 21-26
- Huit, M. (2000) A guide to treating lymphoedema Nursing Standard 96, 38 42
- Keen D.C. (2008) Non-cancer-related lymphoedema of the lower limb Nursing Standard. 22, 24, 53-6.
- King, B. (2006) Diagnosis and management of lymphoedema Nursing Times 102, 13, 47
- Lymphoedema Network (2006) Best Practice for the Management of Lymphoedema International Consensus. London. MEP Ltd
- MacLaren, J.A. MA, (2001) Lymphoedema
- Moffatt et al, (2003) Lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738
- Nigam, Y. & Knight, J. (2008) The Lymphatic System Part 4 – Pathophysiology Nursing Times 104, 16, 24-25
- Penzer, R. (2003) Lymphoedema. Nursing Standard. 17, 35, 45-51.
- Woods, M. (2004) Causes and treatment of early Lymphoedema Cancer Nursing Practice 3, 5, 25-30
- Being overweight
- Having a diet high in red/processed meat
- Being aged 60+ (80% of bowel cancer is in this age group)
- Having a diet low in fibre
- Drinking alcohol
- Having ulcerative colitis or Crohn’s
- Having a family history of bowel cancer
- Having bowel cancer previously, or polyps
In prostate cancer, hormones are used to control testosterone levels. By stopping/reducing testosterone supply, or preventing it reaching prostate cancer cells and therefore restricting their growth, even if the cancer has metastasised. Over 90% of testosterone in the male body is produced in the testicles; testosterone is also produced in the adrenal gland above the kidneys.
Hormone therapy can treat prostate cancer wherever it has metastasised, whether local or advanced. It doesn’t cure cancer but shrinks it or delays its development – sometimes for years. Hormone therapy does not cure cancer but helps to slow its progression. It is sometimes used to shrink the cancer in preparation for radiotherapy, or may be used concurrently. If there is a risk after conclusion of radiotherapy that the cancer may still metastasise, hormone therapy may be continued afterwards for up to six months.
There are several methods employed to impede testosterone reaching the prostate; these can be in the form of tablets to prevent testosterone reaching the prostate, injections or implants to prevent production of testosterone, or orchidectomy (removal of the testicles, or that part of the testicle which produces testosterone).
LHRH agonists (luteinising hormone-releasing hormone) come in the form of implants (zoladex) or injections (prostap, decapeptyl). They are preceded by a course of anti-androgen tablets to prevent the body over-producing testosterone as an initial reaction to beginning LHRH agonist therapy (this is a normal reaction), and therefore to prevent the cancer being able to grow. This course generally lasts two weeks, and is initiated one week before commencing LHRH agonist therapy.
Anti-androgens may also be used separately as hormone therapy in their own right, as they prevent testosterone from reaching the cancer cells. Another hormone used to treat prostate cancer is oestrogen, which slows the cancer’s growth, and kills some cancer cells; it also acts on the testicles, preventing their release of testosterone. This is not a common treatment because of its side effects, such as DVT, CVA and hypertension.
If LHRH agonists are not effective on their own, a ‘maximal androgen blockade’ may be initiated; this involves using an anti-androgen as well as the LHRH agonist. This is not first-line treatment because with the extra drug come extra side effects.
Patients on hormone therapy will have their PSA monitored regularly. Sometimes intermittent hormone therapy is used, this relies on regular PSA results. The patient is given hormone therapy when the PSA is high and when it decreases, the therapy is stopped temporarily. Trials continue, but it is thought that outcomes are the same as those for continuous therapy, but without so many of the side effects.
Hormone therapy for prostate cancer can have significant side effects because of the decreases in testosterone, such as increasing the risk of developing osteoporosis, diabetes, and heart disease. It can also cause erectile dysfunction and loss of libido, hot flushes, gynaecomastia, fatigue and muscle atrophy. Bone density can start to deterioriate within the first six months of treatment with LHRH agonists (although this has not been linked with anti-androgen treatment). Therefore patients need to be encouraged to eat a healthy diet with plenty of fruit and vegetables, being careful to ensure daily intake of 10-20mg vitamin D and 1000-1500mg calcium. Regular exercise is also encouraged, three 30-minute sessions per week is ideal, particularly weight-bearing exercise such as walking, running, or weights. Smoking cessation should be promoted. To reduce the risk of developing heart disease or diabetes it is particularly important to reduce alcohol intake and salt, ensuring a good diet and a healthy lifestyle.
Erectile dysfunction (ED) and loss of libido is a common side effect, about 50% of men undertaking prostate treatment will encounter one or both of these. ED is more likely to be caused by LHRH agonist (stopping the production of testosterone) rather than anti-androgens.
Many patients also experience hot flushes; these can be minimised by attempting to maintain an even temperature, by avoiding spicy foods, using a fan to cool the room, and wearing lightweight clothes, particularly cotton/linen. Consumption of soy products may help, as will stopping smoking.
Some patients will find that on hormone therapy they put on weight, lose muscle tone, or fatigue more easily; exercise is important to counteract these.