01 - SECTION 1 Neoplastic Disorders

SECTION 1 Neoplastic Disorders

Section 1 Neoplastic Disorders Dan L. Longo

Approach to the Patient

with Cancer The application of current treatment techniques (surgery, radiation therapy, chemotherapy, and biologic 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 trau­ matic and revolutionary events that has ever happened to them. Inde­ pendent of prognosis, the diagnosis brings with it a change in a person’s self-image and in their role in the home and workplace. The prognosis of a person who has just been found to have pancreatic cancer is the same as the prognosis of the person with aortic stenosis who develops the first symptoms of congestive heart failure (median survival, ~8 months). However, the patient with heart disease may remain functional and maintain a self-image as a fully intact person with just a malfunctioning part, a diseased organ (“a bum ticker”). By contrast, the patient with pancreatic cancer has a completely altered self-image and is viewed differently by family and anyone who knows the diagnosis. The patient is being attacked and invaded by a disease that could be anywhere in the body. Every ache or pain takes on TABLE 73-1  Distribution of Cancer Incidence and Deaths for 2021 MALE FEMALE SITES % NUMBER SITES % NUMBER Cancer Incidence Prostate

299,010 Breast

310,720 Lung

116,310 Lung

118,270 Colorectal

81,540 Colorectal

71,270 Bladder

63,070 Endometrial

67,880 Melanoma

59,170 Melanoma

41,470 Kidney

52,380 Lymphoma

36,030 Lymphoma

44,590 Pancreas

31,910 Oral cavity

41,510 Thyroid

31,520 Leukemia

36,450 Kidney

29,230 Pancreas

34,530 Leukemia

26,320 All others

200,520 All others

207,440 All sites

1,029,080 All sites

972,060 Cancer Deaths Lung

65,790 Lung

59,280 Prostate

35,250 Breast

42,250 Colorectal

28,700 Pancreas

24,480 Pancreas

25,270 Colorectal

24,310 Liver

19,120 Endometrial

13.250 Leukemia

13,640 Ovary

12,740 Esophagus

12,880 Liver

10,720 Bladder

12,290 Leukemia

10,030 Lymphoma

11,780 Lymphoma

8,360 CNS

10,690 CNS

8,070 All others

87,390 All others

75,4330 All sites

322,800 All sites

288,920 Source: From RL Siegel et al: Cancer statistics, 2024. CA Cancer J Clin 74:12, 2024. Reproduced John Wiley & Sons Ltd.

Oncology and Hematology PART 4 desperate significance. Cancer is an exception to the coordinated interaction among cells and organs. In general, the cells of a multicel­ lular organism are programmed for collaboration. Many diseases 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 the cancer 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 selection to seek advantage over normal cells in a reca­ pitulation of evolution. One consequence of the traitorous behavior of cancer cells is that the patient feels betrayed by their body. The cancer patient feels that they, and not just a body part, are diseased. THE MAGNITUDE OF THE PROBLEM No nationwide cancer registry exists; therefore, the incidence of cancer is estimated on the basis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, which tabulates cancer incidence and death figures from 13 sites, accounting for about 10% of the U.S. population, and from population data from the U.S. Census Bureau. In 2024, 2.001 million new cases of invasive cancer (1,029,080 men and 927,060 women) were diagnosed, and 611,720 per­ sons (322,800 men and 288,920 women) died from cancer. The percent distribution of new cancer cases and cancer deaths by site for men and women is shown in Table 73-1. Cancer mortality continues to decline; however, 6 of the 10 most common cancers have increased in incidence by 1–3% in recent years, and troubling disparities among different racial/ethnic groups persist. Mortality is twice as high in black people than white people for cancers of the prostate, stomach, and uterine corpus. Cancer is the cause of one in four deaths in the United States.