# 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.