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• Avastin (bevacizumab)
• Erbitux (cetuximab)
• Glivec (imatinib)
• Herceptin (trastuzumab)
• Intron A (interferon alfa-2b)
• MabCampath (alemtuzumab)
• Mabthera (rituximab)
• Nexavar (sorafenib)
• Proleukin (aldesleukin)
• Revlimid (lenalidomide)
• Roferon-A (interferon alfa-2a)
• Sprycel (dasatinib)
• Sutent (sunitinib)
• Tarceva (erlotinib)
• Tyverb (lapatinib)
• Vectibix (panitumumab)
• Velcade (bortezomib)

1. Avastin (bevacizumab)

Avastin infusion contains the active ingredient bevacizumab, which is a type of medicine called a humanised monoclonal antibody. It is used to treat cancers of the large intestine and rectum (colorectal cancers) and breast cancers that have spread to other parts of the body. It can also be used to treat advanced lung cancer and advanced kidney cancer.

In order to grow, cancerous tumours need a blood supply that provides the cancer cells with nutrients and oxygen. The growth of the cancer therefore depends on the tumour having a network of blood vessels supplying it.

Cancerous tumours produce substances called growth factors that stimulate nearby blood vessels to grow into the tumour. These new blood vessels allow the cancer cells to grow and multiply and also allow them to spread into other areas of the body through the blood circulation.

Tumours have been found to produce a particular growth factor called vascular endothelial growth factor (VEGF). VEGF stimulates new blood vessels to grow into the tumour.

Bevacizumab acts by neutralising this VEGF. It works in a similar way to the natural antibodies produced by our immune system. Our natural antibodies recognise foreign invaders and bind to them, helping our immune systems to attack them and protect us from infections. Monoclonal antibodies like bevacizumab are made in laboratories and can be used to attack particular proteins in a similar way.

Bevacizumab specifically recognises and binds to the VEGF produced by the tumour. This makes the VEGF unable to stimulate blood vessels to grow. As a result, the cancer’s blood supply is reduced and with it, its supply of oxygen and nutrients. This causes the tumour to shrink, or at least to stop growing.

Medicines that stop the growth of blood vessels in this way are called angiogenesis inhibitors.

As bevacizumab is targeted specifically against the VEGF protein produced by the tumour, it has little effect on healthy cells or existing blood vessels elsewhere in the body.

Bevacizumab is given in combination with chemotherapy treatment that directly attacks and kills the cancer cells. To treat colorectal cancer it can be given with fluoropyrimidine-based chemotherapy such as 5FU (fluorouracil) and folinic acid, irinotecan, capecitabine or oxaliplatin. To treat breast cancer it is given in combination with paclitaxel. To treat lung cancer it is given in combination with platinum-based chemotherapy. To treat kidney cancer it is given in combination with interferon alfa-2a.

Bevacizumab is given as a drip into a vein (intravenous infusion) once every two or three weeks. The first dose is administered over 90 minutes. If this is well tolerated, the next dose may be given over 60 minutes; if this is also well tolerated all further doses may be given over 30 minutes.

What is it used for?

• Cancer of the large bowel (colon) and rectum (colorectal cancer) that has spread to other areas of the body.
  
  
• Breast cancer that has spread to other areas of the body.
  
  
• Advanced non-small cell lung cancer (NSCLC).
  
  
• Advanced kidney cancer and/or kidney cancer that has spread to other areas of the body.
  
  

Warning!

• This medicine may interfere with the wound healing process because it impairs the growth of new blood vessels. For this reason, treatment with this medicine should not be started until at least 28 days after major surgery, or until any wound from surgery is fully healed. If you need to have any operations, treatment with this medicine will need to be interrupted.
  
  
• Your doctor will need to regularly check your blood pressure and levels of protein in your urine while you are having treatment with this medicine.
  
  
• This medicine may decrease the number of blood cells in your blood. A low white blood cell count can increase your susceptibility to infections; a low red blood cell count causes anaemia and a low platelet count can cause problems with blood clotting. For this reason, you may need regular blood tests to monitor your blood cells during treatment with this medicine. Tell your doctor immediately if you experience any of the following symptoms during your treatment, as they may indicate problems with your blood cells: unexplained bruising or bleeding, purple spots, sore mouth or throat, mouth ulcers, high temperature (fever) or other signs of infection, or suddenly feeling tired, breathless, or generally unwell.
  
  
• This medicine can sometimes cause a blood clot in a vein (DVT) or an artery (which could cause a heart attack or stroke). For this reason, you should let your doctor know immediately if you get any of the following symptoms during treatment: stabbing pains and/or unusual swelling in one leg, pain on breathing or coughing, coughing up blood, sudden breathlessness, sudden severe chest pain, sudden disturbance in vision, hearing or speech, sudden weakness or numbness on one side of the body, fainting or collapse.
  
  
• Tell your doctor immediately if you experience seizures (fits), headache, confusion or changes in vision during treatment with this medicine.
  
  
• This medicine may be harmful to an unborn baby. For this reason, women receiving this medicine should use an effective method of contraception to prevent pregnancy, both during treatment and for at least six months after treatment is finished. Women should consult their doctor immediately if they get pregnant.
  
  

Use with caution in

• People over 65 years of age.
  
  
• People with inflammation in the gut or abdomen (eg diverticulitis, stomach ulcers, colitis associated with chemotherapy).
  
  
• History of high blood pressure (hypertension).
  
  
• Uncontrolled high blood pressure (hypertension).
  
  
• History of stroke or mini-stroke (transient ischaemic attack).
  
  
• History of heart attack.
  
  
• Angina.
  
  
• Heart failure.
  
  
• People with blood clotting problems.
  
  
• People having treatment with anticoagulant medicines for a blood clot.
  
  
• People who have previously been treated with radiotherapy to the chest or with anthracycline chemotherapy medicines such as doxorubicin.
  
  
• People who have recently had major surgery or any major wounds.
  
  

Not to be used in

• Allergy to Chinese hamster ovary (CHO) cell products or other recombinant human or humanised antibodies.
  
  
• People with tumours that have spread to the brain or spinal cord (central nervous system) and have not been treated.
  
  
• People who have recently had any bleeding in the lungs or have been coughing up blood.
  
  
• Pregnancy.
  
  
• Breastfeeding.
  
  
• The safety and efficacy of this medicine have not been established in children and adolescents under 18 years of age. It is not recommended for this age group.
  
  

This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Pregnancy and breastfeeding

Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.

• This medicine must not be used during pregnancy. It could be harmful to a developing foetus because it stops the formation of new blood cells. Women who could get pregnant must use effective methods of contraception to prevent pregnancy while having treatment with this medicine and for at least six months after the treatment is finished. Seek medical advice from your doctor. Inform your doctor immediately if you think you could be pregnant at any point during treatment.
  
  
• It is not known if this medicine passes into breast milk. However, as it could harm the development of the infant if it does pass into breast milk; mothers should not breastfeed during treatment with this medicine, or for at least six months after their last dose. Seek medical advice from your doctor.
  
  

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

• Raised blood pressure (hypertension).
  
  
• Diarrhoea.
  
  
• Nausea and vomiting.
  
  
• Feeling of weakness or fatigue.
  
  
• Decreased number of white blood cells, red blood cells or platelets in the blood.
  
  
• Feeling of numbness or tingling in hands or feet.
  
  
• Slow wound healing.
  
  
• Infections.
  
  
• Bleeding.
  
  
• Headache.
  
  
• Constipation.
  
  
• Abdominal pain.
  
  
• Fever.
  
  
• Pain.
  
  
• Sore mouth.
  
  
• Loss of appetite.
  
  
• Change in taste.
  
  
• Shortness of breath.
  
  
• Blood clot in a vein of the leg (deep vein thrombosis).
  
  
• Blood clot in an artery, causing a heart attack or stroke.
  
  
• Heart failure.
  
  
• Formation of holes (perforation) in the wall of the stomach or intestine.
  
  
• Formation of abnormal tube-like connections between organs that are not normally connected or between an organ and the skin (fistulae).
  
  
• Protein in the urine, which may be linked to kidney problems.
  
  

The side effects listed above may not include all of the side effects reported by the drug's manufacturer.

For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?

You should tell your doctor or pharmacist if you are taking any other medicines, including those bought without a prescription and herbal medicines, before starting treatment with Avastin. Similarly, you should also check with your doctor or pharmacist before taking any new medicines while you are still receiving treatment with Avastin, so they can check that the combination is safe.

People who have had treatment with an anthracycline chemotherapy medicine, such as doxorubicin, epirubicin or idarubicin, before starting treatment with this medicine may have a higher risk of side effects on the heart.

Other medicines containing the same active ingredient

There are currently no other medicines available in the UK that contain bevacizumab as the active ingredient.

What is bowel cancer?

Bowel is the general term for the long muscular tube that starts at the bottom of the stomach and ends at the anus.

The first part of the bowel is involved with the digestion of food and is known as the 'small bowel' because the tube is narrower here.

The 'large bowel' follows the small bowel and in a healthy person, the main part of the large bowel (colon) is responsible mostly for absorbing water from the faeces. The last part of the large bowel is known as the rectum, which leads to the anus.

Bowel (colorectal) cancer is cancer of the colon or rectum, and it arises from the cells that line the bowel. The small bowel is strikingly free from cancer risk, and almost all bowel cancers arise in the large bowel.

About 6 per cent of the population in Western countries develop bowel cancer at some time during their lives, making this the second commonest cause of cancer-related death. However, it is curable in 40 to 50 per cent of cases, usually by surgery.

The cancer develops when one of the cells in the colon develops a series of changes (mutations) in some of the genes that control how the cell divides and survives. As a result, the cell divides uncontrollably to form a clump of malignant (cancerous) cells. Initially, these cell changes commonly produce a polyp (a clump of abnormal cells the size of a pea on the end of a stalk of normal cells) called an adenoma.

At this stage, an adenoma is still pre-cancerous (a stage at which it may or may not become cancer), and probably only about 5 per cent of the polyps progress further to become life-threatening cancers.

The polyp enlarges very slowly, probably over about 10 years, up to between 1cm and about 5cm in diameter. The abnormal cells first invade the stalk of the polyp, then the underlying tissue of the colon to which the stalk is attached. This invasion indicates that cancer has developed. The patient will then usually have symptoms, which can include bleeding from the ulcerated tip of the cancer and diarrhoea caused by disturbance in the muscle activity of the colon or to obstruction. The risk of invasive cancer becomes appreciable once the polyp diameter has exceeded 1cm.

About 30 per cent of bowel cancers arise from flat lesions and do not pass through a polyp stage. This particularly occurs with cancers of the proximal (right-sided) colon and caecum.

If the cancer is not removed quickly, cancerous cells can break off from the tumour and move through veins or lymph vessels to form tumour growths (called metastases or secondaries) elsewhere, particularly in lymph glands or in the liver. The cure rate falls sharply once this has happened.

The average age when bowel cancer is first discovered is 65, and it becomes increasingly common with advancing age. Very occasionally, it may affect much younger adults from the age of 20. The rates do not differ strikingly between the sexes, although men are slightly more prone to developing rectal cancer and women to developing cancer of the caecum. This is the point where the appendix is attached.

The appendix itself is rarely the site of cancer, although it can be the site of a much rarer tumour called a 'carcinoid'. Previous appendicectomy (removal of the appendix) seems to have no effect on the subsequent risk of bowel cancer.

What causes bowel cancer?

No cancers are fully understood, but bowel cancer is better understood than most.

Studies of migrating populations, for example Japanese migrants who move to Hawaii, have shown that people rapidly acquire the risk of developing bowel cancer that is found in the country to which they have moved.

About 90 per cent of the risk for bowel cancer is thought to be due to dietary factors, with the other 10 per cent due to genetic (inherited) factors.

Dietary factors

Dietary factors that increase bowel cancer risk are not yet clearly defined. Populations with a high-fibre intake tend to have a low risk of bowel cancer. However, the results of studies in which people, usually those who have already developed polyps, have been given high-fibre diets are disappointing.

It now seems as though the beneficial effect of fibre is not simply due to its mechanical effect on helping the bowel to regularly pass faeces.

Evidence suggests that vegetable fibre is more protective that cereal fibre. Recent studies have also shown that specific chemicals in vegetables, for example the isothiocyanates, which give brassicas (cabbage, broccoli, brussel sprouts, cauliflower) their characteristic pungent taste, might be especially protective against cancer. A high intake of calories and obesity are both risk factors for bowel cancer, and a high intake of red meat is also linked with increased risk.

The best available approaches for a low risk of developing bowel cancer are:


• a diet high in green vegetables, particularly cabbage, broccoli, brussel sprouts or cauliflower.
  
  
• a diet low in red meat. In particular, avoid burnt meat, which contains cancer-promoting chemicals called cyclic amines.
  
  
• keeping to a normal body weight and taking regular exercise.
  
  
• Although still controversial, it seems that taking aspirin (eg Disprin) regularly (300mg per day or more ie one standard tablet) reduces the risk by about 50 per cent. However, prolonged use of aspirin carries a risk of intestinal ulceration and bleeding, so whether the benefits would outweigh the risks is unclear at present.
  
  

Genetic factors

Approximately 10 per cent of bowel cancers have a strong genetic factor. The commonest is hereditary non-polyposis colon cancer (HNPCC or Lynch syndrome). This condition is caused by mutation in any one of at least five different genes. These genes carry the instructions for manufacturing proteins that can repair damaged DNA.

Inheritance of this type of cancer is autosomal dominant, which means that half the children of someone with HNPCC are at risk of inheriting the condition. When these genes are defective, DNA repair does not take place, and damaged (mutant) DNA accumulates within cells, greatly increasing the cancer risk.

The colon is not the only organ affected. The syndrome also carries an increased risk of cancers of the stomach, ovaries, breasts and uterus.

The bowel cancers in affected individuals tend to develop as flat lesions rather than as polyps. The cancers more commonly affect the proximal (right sided) colon, whereas other cancers are more common in the distal colon (nearer the rectum) or rectum. They occur at a younger age and this condition should be suspected in anyone who develops bowel cancer before the age of 45.

About 1 per cent of bowel cancers occur in people who inherit a defect in the gene for familial polyposis coli. These people develop hundreds of adenomatous (pre-cancerous) polyps in the colon by the time they are in their teens and almost invariably develop bowel cancer by middle age unless the colon is removed.

Patients with ulcerative colitis or Crohn's disease of the colon (conditions that together affect about 1 in 800 of the population in Western countries) have about a five-fold increased risk of bowel cancer.

The risk is greater if the colitis (colon inflammation) seen in both conditions affects the whole colon, and if it has been present for more than ten years. The risk is probably reduced by regularly taking mesalazine (5-aminosalicylic acid), a medication that is widely used to reduce the risk of relapse in these diseases.

What are the symptoms of bowel cancer?

Because early cancers often cause no symptoms, screening of symptom-free individuals is being considered. About 85 per cent of people with bowel cancer are currently not diagnosed until the cancer has penetrated through the bowel wall or spread to lymph nodes or elsewhere. Cure is nevertheless still possible. The earliest symptom is often bleeding from the back passage. Later changes include loss of the normal form of bowel motions sometimes followed by diarrhoea.

Constipation can also occur. If the growth starts to block the bowel then colicky lower abdominal pain (ie coming in waves each of which lasts for a few minutes) can develop. If the bowel becomes completely obstructed, severe abdominal pain and vomiting occurs, followed by complete constipation. This obstruction is a surgical emergency requiring immediate admission to hospital, since the bowel is at risk of becoming gangrenous if the obstruction is not relieved.

In the proximal colon, the lumen (the space inside) is larger (about 4 or 5cm in diameter) and less likely to become obstructed. Cancers of this part of the colon, including the caecum, tend to show themselves very subtly as iron-deficiency anaemia, due to loss of small amounts of blood over a long period of time. The anaemia can lead to symptoms of pallor, shortness of breath or simply tiredness.

Cancers of the rectum typically cause rectal bleeding, which can easily be mistaken for bleeding haemorrhoids (piles). Other symptoms include the feeling that you haven't fully emptied your bowel accompanied by a need to frequently empty the bowel. Loss of appetite and weight loss tend to be late features in bowel cancer.

How is bowel cancer diagnosed?

The doctor might feel a cancer of the rectum by inserting a gloved finger into the rectum. The diagnosis should usually be confirmed by biopsy in which a small (2mm diameter) sample of tissue is taken painlessly with forceps inserted through a small tube (a proctoscope or sigmoidoscope).

To spot cancers further along the colon, the doctor will use either a flexible sigmoidoscope (to see the part of the colon nearest the rectum, including the sigmoid [bendy] colon on the left side of the abdomen) or a colonoscope (to see the whole colon, including the part on the right side of the abdomen).

Colonoscopy is usually performed using intravenous sedation and takes about 30 minutes. Flexible sigmoidoscopy takes about 10 minutes and can usually be done without sedation.

Alternatively, a barium enema examination may be used to look at the whole colon. In this test, a liquid suspension of barium sulphate, which shows up on X-rays, is poured into the rectum through a narrow tube inserted through the anus. Usually a small balloon is then inflated in the rectum to pump in a small amount of air. This gives 'double contrast' to show the lining of the bowel in good detail. The procedure takes about 30 minutes.

For both procedures, the colon needs to be cleared by quite vigorous purgation (medicines are given to stimulate the intestines and clear out the bowel), which many patients find the most unpleasant aspect of the procedure.

There are advantages and disadvantages of each approach:

• colonoscopy allows biopsy and therefore the presence of cancer can be confirmed under the microscope. But, even in skilled hands, the whole colon is seen in only about 90 per cent of procedures. Colonoscopy can be uncomfortable, but it is usually performed with sedation, which has the added advantage that the individual usually cannot remember the procedure. Complications include a slight risk of perforation (puncturing) of the bowel and a very slight risk of death (about 1 per 5000).
  
  
• the barium enema is usually more comfortable, but it is performed without sedation. It nearly always shows up the whole colon, but in less detail than colonoscopy so very small polyps can be missed.
  
  

Scanning techniques (CT scanning or ultrasound) are increasingly being studied as possible ways to diagnose bowel cancer, but they are not yet reliable enough for routine use.

Screening is now recommended in the USA for all individuals over the age of 50. It is done by a combination of an annual test for non-visible (occult) blood in the faeces (faecal occult blood test), plus some form of endoscopy, either flexible sigmoidoscopy or colonoscopy, every three to five years. Experts have not yet firmly established whether this approach can prolong life, and screening has not yet been introduced routinely in the UK.

A positive faecal occult blood test is linked with approximately a 10 per cent chance of cancer or a 34 per cent chance of a polyp. However, the test is negative with up to 50 per cent of cancers (this figure falls to about 30 per cent when the test is done on three consecutive days). Therefore, this test is not sufficiently reliable for routine diagnosis of symptom free patients.

The need for screening is different if you have a strong family history of bowel cancer. In individuals who have a first-degree relative (eg a parent, brother, sister or child) who developed colorectal cancer before the age of 45, the life-time risk for colorectal cancer is 1 in 10.

The consensus of opinion is that such individuals should be offered screening, probably by full colonoscopy, every five years, starting 5 to 10 years younger than the age at which the relative was diagnosed. Individuals who have two first-degree relatives with colorectal cancer have a one in six life-time risk and should be similarly offered screening.

What other conditions might cause similar symptoms?

This depends on the symptoms.

Rectal bleeding


• It is extremely common to notice a few spots of blood on the toilet paper after passing stools. If there is no blood in the toilet bowl, this is most likely to be due to minor damage to a blood vessel in the skin of the anus. If it persists, the problem requires investigation to exclude significant disease of the anus.
  
  
• Blood in the toilet bowl that is separate from the faeces and is bright red is commonly due to bleeding from haemorrhoids (piles). However, this sort of bleeding cannot be distinguished from bleeding due to a rectal cancer without further investigation.
  
  
• Blood that is mixed in with the stool is more likely to have a worrying cause but benign (non-cancerous) possibilities include bleeding from diverticular disease or from colitis.
  
  

Diarrhoea or other change in bowel habit

Diarrhoea that has only been present for a few days, or even up to three weeks, is most commonly due to infection ie gastroenteritis. Diarrhoea that carries on for longer than three weeks is rarely due to infection and requires urgent investigation.

Benign causes include:


• colitis, an inflammation of the colon (eg ulcerative colitis or Crohn's colitis).
  
  
• diverticulitis, an inflammation of the little pea-sized pouches that can develop in the wall of the bowel, in which case the diarrhoea may be bloody.
  
  
• lactose intolerance.
  
  
• irritable bowel syndrome (IBS), in which case the diarrhoea is watery and not bloody. Irritable bowel syndrome mimics some of the symptoms of bowel cancer including colicky abdominal pain and diarrhoea. However, the diarrhoea is always non-bloody, the symptoms are intermittent and IBS typically starts in the adolescent or young adult at an age when bowel cancer is very rare.
  
  

Anaemia

Iron deficiency anaemia indicates that someone has been losing small amounts of blood over a long time. Causes include heavy menstruation (periods), coeliac disease (gluten intolerance), oesophagitis (inflammation of the gullet), Crohn's disease and cancer of the stomach. Iron deficiency because of lack of iron in the diet is an uncommon cause, except in adolescents with a poor diet.

Abdominal pain

Bowel cancer may cause lower abdominal pain that is typically colicky. Similar pain occurs in irritable bowel syndrome, but is often associated with diarrhoea that alternates with formed or even constipated stools, whereas bowel disturbance in bowel cancer is usually more persistent.

Irritable bowel syndrome may be triggered by stress or by an episode of infectious gastroenteritis. It most commonly presents in adolescents or young adults at an age when bowel cancer is rare.

Crohn's disease, a form of inflammatory bowel disease, can also present with colicky pains with or without diarrhoea. Diagnosis is usually based on barium radiology or colonoscopy when it can be readily distinguished from cancer. Crohn's disease commonly affects the small intestine, a part of the bowel that is exceptionally rarely the site of cancer.

Pain at the very lowest part of the abdomen (suprapubic pain) can indicate a bladder problem such as cystitis, and pain low down to the right or left in a woman can indicate disease of the ovaries. Urine testing and pelvic ultrasound examination are usually done if these are possible alternative diagnoses.

What can your doctor do?

You should see your doctor promptly if you have:

• persistent rectal bleeding.
  
  
• a change in bowel habit (persistent diarrhoea or constipation that is unusual for you).
  
  
• recurring abdominal pains or unexplained tiredness.
  
  

Your doctor will probably feel your abdomen and perform an internal rectal examination using a gloved finger. He or she might also send off blood tests, especially a full blood count to check for anaemia. Occasionally, the doctor's practice might be equipped for sigmoidoscopy.

Unless your symptoms are considered low risk for cancer (perhaps because of a combination of your youth and the lack of recurrence or persistence of symptoms), you are likely to be referred to your district hospital.

You will usually be seen either by a physician who specialises in bowel diseases (a gastroenterologist) or by a surgeon with a gastroenterological practice. In either case, the procedures they use to make a diagnosis are likely to be the same. They will consist of some form of endoscopic examination (either sigmoidoscopy or colonoscopy), often followed by a barium enema radiological examination.

In the UK, the July 2000 two week cancer guidelines suggest that anyone over 55 with rectal bleeding, or anyone with a combination of rectal bleeding and altered bowel habit, should be seen at a hospital within two weeks of referral by their GP.

Fortunately, bowel cancers are fairly slow growing; estimates are that it takes about 10 years on average for a small polyp to develop into an invasive cancer. Nevertheless, even if your symptoms and age do not put you into the category of people needing to be seen within two weeks, a delay of more than about two months should be regarded as unacceptable.

What can you do yourself?

Prevention and early diagnosis


• Ensure a regular daily intake of green vegetables, particularly brassicas (cabbage, broccoli, sprouts or cauliflower). Do not eat red meat (beef and lamb) more than about once per week. Keep your weight normal and take regular exercise.
  
  
• See your doctor to discuss screening if you have a first-degree relative who has developed bowel cancer before the age of 45, or if you have two or more first-degree relatives who have developed bowel cancer.
  
  
• See your doctor promptly if you notice rectal bleeding (other than very occasional spotting on the paper only), diarrhoea that persists for more than a week, recurring lower abdominal pain or persistent tiredness or shortness of breath.
  
  

Treatment

Once a cancer has developed, treatment is aimed at removing the original (primary) growth and at preventing secondary spread. This will be with some combination of surgery, chemotherapy or radiotherapy.

You should:


• ensure that you seek advice as early as possible after symptoms develop.
  
  
• get good nutrition.
  
  
• stay positive, remembering that more than half of patients with bowel cancer are cured.
  
  

Do not hesitate to nag, or have someone nag on your behalf, if you feel you are not being investigated or treated appropriately or speedily.

What can your doctor do?

Once the diagnosis of bowel cancer has been made, the first treatment is usually surgical removal of the cancerous tumour under general anaesthetic.

If the cancer is in the rectum, the operation will usually be accompanied by radiotherapy (by external beam irradiation) to reduce the risk of tumours reappearing in the same area. The radiotherapy may sometimes be given first, followed a few months later by the surgery.

For cancer of the colon, radiotherapy is not routinely used, but if examination of cells from the removed cancer shows that the cancer has spread to lymph glands, then some form of chemotherapy will normally be given, usually oral 5-fluorouracil combined with either folinic acid (eg Leucovorin) or levamisole. Chemotherapy is very likely to cause side effects, including nausea and hair loss, but the nausea can usually be well controlled by drugs.

In any form of bowel surgery, the patient is normally warned that the surgeon might have to create a colostomy stoma (opening of the bowel onto the abdomen that is covered by a bag). This might be a temporary measure to divert faeces from the site of the bowel that has been repaired after removal of the tumour.

If the tumour is very low down in the rectum, then the primary operation will include cutting out and closing the anus (abdomino-perineal resection) so the stoma will be permanent. Fortunately, modern stoma accessories are excellent, and colostomies are generally well managed and odour free.

In most cases, a bowel cancer higher up the colon can be surgically removed and the bowel repaired without the need for a colostomy.

The average length of stay in hospital for bowel cancer surgery is about 7 to 10 days. The abdominal wound is usually in the middle of the abdomen. Stitches will be removed by about 7 to 10 days, but the scar will usually cause some discomfort for four to six weeks. Pain relief immediately after the operation should nowadays be very effective and is often under the patient's own control.

The best way to monitor patients after surgery is not yet clearly established, but some surgeons review patients at regular intervals to have a blood test done (carcino-embryonic antigen) to look for any evidence that the cancer has returned. This test is partly done because tumours that have re-appeared in the same area can be removed and partly because surgeons are now more optimistic about the chances of curing bowel cancer that has spread to the liver, provided it is caught early.

Prognosis (outlook)

Colorectal cancer has a relatively good prognosis compared with most other solid cancers. Between 50 and 60 per cent of people with colorectal cancer survive for five years, after which a return of the cancer is uncommon. If the disease is caught at a time when the tumour has not spread through the bowel wall (so-called Dukes grade A), then the cure rate is over 90 per cent.

Complications

Investigations

Colonoscopy carries a perforation rate of about 1 per 300 procedures, and a death rate of 1 per 5000. Perforation may be the result of polypectomy (polyp removal), particularly in the right colon where the bowel wall is thinner and where polyps more commonly have a flat base.


• Significant bleeding requiring blood transfusion occurs in about 1 per 100 cases after polypectomy and is usually due to bleeding from an incompletely clotted artery in the remaining polyp stalk.
  
  
• The rectal balloon catheter used for barium enema can very rarely cause perforation.
  
  
• The laxatives used as bowel preparation for colonoscopy or barium enema can occasionally cause a significant fall in blood pressure and fainting. Considerable changes in body fluids and in salts such as sodium and potassium can also occur.
  
  
• Significant problems rarely happen in individuals who are otherwise in good health, but particular care is needed in people with kidney disease or with heart problems. If these other conditions are significant, the bowel preparation might have to be performed in hospital.
  
  

Surgery

About 5 in every 100 patients will die by 30 days after an operation to remove bowel cancer. Possible complications after surgery include:

• leakage from the repaired bowel that can sometimes require a second operation at the same site.
  
  
• paralysis of the intestines (ileus), which is usually temporary and recovers spontaneously after a few days.
  
  
• the complications of any operation under general anaesthesia, including deep vein thrombosis, pulmonary embolism and pneumonia.
  
  

Patients are routinely given antibiotics to prevent infection from any minor leakage of the repaired bowel, and preventive anticoagulation (blood thinning treatment) with heparin to protect against possible deep vein thrombosis.

The goal of breast cancer surgery is to remove localized cancer (cancer that hasn't spread to other areas of the body) by removing the tumor itself and a portion of surrounding tissue, while conserving as much of the breast as possible.

What Are My Options For Surgery?

Various surgical techniques differ in the amount of breast tissue that is removed with the tumor, depending on the tumor's characteristics, whether it has spread (metastasized) and your personal feelings. The surgeon often removes some lymph nodes under the arm as part of the operation, so they can be tested for the presence of cancer cells. This will help your doctor plan your treatment after surgery.

The breast surgeon will discuss your surgery options with you before the procedure. A specific surgical procedure may be recommended for you based on the size, location, or type of breast cancer you have. Some of the procedures you may discuss with your physician include:

• Lumpectomy
• Partial or Segmental Mastectomy or Quadrantectomy
• Total Mastectomy
• Modified Radical Mastectomy
• Radical Mastectomy

Lumpectomy

This is also referred to as breast conserving therapy. The surgeon removes the cancerous area and a surrounding margin of normal tissue. A second incision may be made in order to remove the lymph nodes. This treatment aims to maintain a normal breast appearance when the surgery is over.

After the lumpectomy, a five- to eight-week course of radiation therapy is often used to treat the remaining breast tissue. The majority of women who have small, early-stage breast cancers are excellent candidates for this treatment approach.

Women who are not usually eligible for a lumpectomy include those who have already had radiation therapy to the affected breast, have two or more areas of cancer in the same breast that are too far apart to be removed through one incision, or have cancer that was not completely removed during the lumpectomy surgery.

Partial or Segmental Mastectomy or Quadrantectomy

The surgeon removes more breast tissue than with a lumpectomy. The cancerous area and a surrounding margin of normal tissue are removed, and radiation therapy is usually given after surgery for six to eight weeks.

Simple or Total Mastectomy

The entire breast is removed, but no lymph nodes are removed in this procedure. Simple mastectomy is most frequently used for further cancer prevention or when the cancer does not go to the lymph nodes.

Modified Radical Mastectomy

The surgeon removes all of the breast tissue along with the nipple. Lymph nodes in the armpit are also removed. The chest muscles are left intact. For many patients, mastectomy is accompanied by either an immediate or delayed breast reconstruction. This can be done quite effectively using either breast implants or the patient's own tissue -- usually from the lower abdomen.

One in three people will contract cancer, and one in four will die from the disease.

Within five years, cancer will surpass heart disease as the leading cause of death, according to the American Hospital Association.

In 1994, 1.2 million new cancer cases were added to the more than eight million people in the U.S. who have already been diagnosed with cancer.

Since 1950, the overall cancer incidence has increased by 44 percent; the incidence of breast cancer and male colon cancer by about 60 percent; testis, prostate and kidney by 100 percent; and other cancers, such as malignant melanoma, multiple myeloma and some lymphomas, by over 100 percent.

The estimated annual cost of cancer to the United States, excluding incalculable psychosocial costs, is $110 billion, approximately 2 percent of the GNP.

An estimated 80 million people have health insurance insufficient to cover the costs of a catastrophic illness such as cancer.

Annual production rates for synthetic, carcinogenic and other industrial chemicals exploded from 1 billion pounds in 1940 to more than 500 billion pounds annually during the 1980s.

Recent National Cancer Institute studies have linked: non-Hodgkin's lymphoma and exposure to solvents, oils, and greases; elevated risks for multiple myelorna among men and women employed in the textile and plastic industries; lymphoma among laboratory workers at the U.S. Department of Agriculture; and lung cancer among workers who developed silicosis.

The rates of certain types of cancer among some industrial workers are up to 10 times higher than in the general population. Children of workers handling chemical carcinogens have sharply increase cancer rates. For example, the risks of childhood leukemia are increased two-to-five-fold if, during their mother's pregnancies, their fathers worked with spray paints, dyes or pigments.

Some 75 percent of all cancers develop in those over 55, but notable exceptions include childhood leukemia, testicular and brain cancers - which mainly strike young people and have been increasing at an alarming rate, particularly among peak age groups For example, there has been an approximate 300 percent increase in testicular cancer among those aged 25-34 since the 1950s.

During the 1990s, nearly 2 million women will have been diagnosed with breast cancer and 460,000 will have died. Between 1950 and 1989, the incidence of breast cancer increased by 53 percent.

There has been an approximate doubling in. lung cancer rates in recent decades among non- smokers. A wide range of occupational exposures and urban air pollution have been shown to cause lung cancer.

"Occupational studies have played a major role in identifying well-established environmental carcinogens, such as asbestos, benzene, arsenic, aromatic amines, coal tars, vinyl chloride, chromium, and wood dust." Measures of Progress Against Cancer - Cancer Prevention, Significant Accomplishments 1982-1992, The National Cancer Institute.

"It is well established that primary prevention is the most effective means of disease control. This is particularly true of cancer." Measures of Progress Against Cancer - Cancer Prevention.

"Lack of appreciation of the potential hazards of environmental and food source contaminants, and laws, policies, and regulations protecting and promoting tobacco use worsen the cancer problem and drive up health care costs." Cancer At a Crossroads: A Report to Congress for the Nation, National Cancer Advisory Board, September 1994.

"While individuals have a responsibility to change high-risk behavior, government and society have responsibilities to identify and prevent workplace and environmental hazards, restrict advertising of unsafe products, require accurate product labeling, and provide culturally targeted education about cancer risk and prevention." Cancer At a Crossroads

"The elimination or reduction of exposure to carcinogenic agents is a priority in the prevention of cancer. We are just beginning to understand the full range of health effects resulting from the exposure to occupational and environmental agents and factors." Cancer at a Crossroads

"We spend close to $100 billion a year on cancer treatment in this country. If we are going to get on top of this problem, we absolutely have to focus more on prevention." Dr Devra Lee Davis, senior adviser to the assistant secretary for health and human services. Washington Post, February 14.

"Everyone should know that the 'war on cancer' is largely a fraud." Linus Pauling, two-time Nobel laureate.

"No one should think that because the [Environmental Protection Agency] allows it, a pesticide is safe. No pesticide is safe. They're designed to kill living organisms. They should be treated with respect -including the warnings on the label." Jerome Blondell, EPA's pesticides office. USA Today, February 27,1995.

Cancer (medical term: malignant neoplasm) is a class of diseases in which a group of cells display uncontrolled growth (division beyond the normal limits), invasion (intrusion on and destruction of adjacent tissues), and sometimes metastasis (spread to other locations in the body via lymph or blood). These three malignant properties of cancers differentiate them from benign tumors, which are self-limited, and do not invade or metastasize. Most cancers form a tumor but some, like leukemia, do not. The branch of medicine concerned with the study, diagnosis, treatment, and prevention of cancer is oncology.

Cancer may affect people at all ages, even fetuses, but the risk for most varieties increases with age. Cancer causes about 13% of all deaths. According to the American Cancer Society, 7.6 million people died from cancer in the world during 2007. Cancers can affect all animals.

Nearly all cancers are caused by abnormalities in the genetic material of the transformed cells^{[citation needed]}. These abnormalities may be due to the effects of carcinogens, such as tobacco smoke, radiation, chemicals, or infectious agents. Other cancer-promoting genetic abnormalities may be randomly acquired through errors in DNA replication, or are inherited, and thus present in all cells from birth. The heritability of cancers are usually affected by complex interactions between carcinogens and the host's genome. New aspects of the genetics of cancer pathogenesis, such as DNA methylation, and microRNAs are increasingly recognized as important.

Genetic abnormalities found in cancer typically affect two general classes of genes. Cancer-promoting oncogenes are typically activated in cancer cells, giving those cells new properties, such as hyperactive growth and division, protection against programmed cell death, loss of respect for normal tissue boundaries, and the ability to become established in diverse tissue environments. Tumor suppressor genes are then inactivated in cancer cells, resulting in the loss of normal functions in those cells, such as accurate DNA replication, control over the cell cycle, orientation and adhesion within tissues, and interaction with protective cells of the immune system.

Diagnosis usually requires the histologic examination of a tissue biopsy specimen by a pathologist, although the initial indication of malignancy can be symptoms or radiographic imaging abnormalities. Most cancers can be treated and some cured, depending on the specific type, location, and stage. Once diagnosed, cancer is usually treated with a combination of surgery, chemotherapy and radiotherapy. As research develops, treatments are becoming more specific for different varieties of cancer. There has been significant progress in the development of targeted therapy drugs that act specifically on detectable molecular abnormalities in certain tumors, and which minimize damage to normal cells. The prognosis of cancer patients is most influenced by the type of cancer, as well as the stage, or extent of the disease. In addition, histologic grading and the presence of specific molecular markers can also be useful in establishing prognosis, as well as in determining individual treatments.