There are basically three causes (“etiologies”) of cancer symptoms. The first is the cancer itself — by definition a malignant tumor can spread to anywhere in the body. This means than any of the body’s numerous systems may be affected. It is unusual to cure cancers when they become widespread(“disseminated”) although there are notable exceptions (e.g. choriocarcinoma, germinoma, thyroid cancer, leukemias). In general, organ cancers (e.g. lung, liver, esophagus, stomach, pancreas, colorectal, kidney, prostate, bladder, breast) have particular ability to spread(“metastasize”) to“distant sites” and cause symptoms there. The cancer causes symptoms by“invasion” both locally (the site of the“primary tumor” ) and distantly (the“metastatic sites” ). This invasion may be into lymph glands, which are normally pea-sized filters for blood serum; they interconnect to “lymph channels” to return the purified serum to the bloodstream. The lymph glands (“nodes”) normally contain white blood cells, when they are invaded by infection or cancer they can swell to large sizes (“lymphadenopathy”) and press on neighboring structures. Cancer can directly “eat” through organ walls(“perforation”), causing spillage of their contents. This may lead to infection such as “peritonitis”(internal abdominal infection from bowel contents leakage),“mediastinitis” (from leakage of food and bacteria into the center of the chest) or “cutaneous emphysema” (air in the lung leaking out through a hole into surrounding tissues). Also, a growing tumor can block off (“obstruct”) hollow organs, such as the esophagus, larynx, lung, intestine, colo-rectum, bladder and cervix. This obstruction may lead to malnutrition, breathing difficulty (“dyspnea”), trouble passing urine(“voiding”) or stool (“defecation”) . Furthermore, cancer can invade nerves, causing local pain, or enlarge organs (i.e. “Hepatomegly” –liver enlargement , “Splenomegaly” –spleen enlargement) and exert pressure on their nerve-rich capsules, causing pain. The bone may be invaded leading to“pathologic fractures” in weight bearing areas, or the brain leading to“neurological symptoms” (e.g. seizures, coordination, motor and sensory problems, judgment and memory lapse). The cancer can invade the bone marrow causing diminution of normal blood cell output (“erythrocytes”[red cells], “ leukocytes” [white cells], and “platelets” [fragments used for clotting]. The tumor itself may produce unusual biochemical substances leading to remarkable effects from so called“Paraneoplastic Syndromes” (“PNS”) . These effects include change of skin color, spontaneous clotting of blood in veins (“thrombophlebitis”), imbalance(“cerebellar ataxia”, and metabolic disturbances including changes in blood electrolytes, increased steroid or hormone production or acute weight loss. They are not all listed here since they are varied and rare (about 2% of patients get a PNS). Moreover, the general effect of advanced cancer can reduce a persons appetite (“anorexia”), cause them to become too thin(“cachexia”), fatigued, debilitated, and depressed. Most of these above symptoms have effective palliative treatments.
The second category is that the symptoms can arise from thetreatment itself. Surgery, Radiation, Chemotherapy and Hormones all have Side-Effects (listed in particular Transcripts for specific cancers). These side effects may include skin irritation, pain, nausea and vomiting, bone brittleness, hair loss, and lowered blood counts leading to fatigue and infections, easy bruising and internal bleeding. Drugs may have unusual effects in any given given patient(“idiosyncratic reactions”) which are unpredictable. Undeniably, there have been many cases where the “treatment was worse than the disease”, and the patient not only failed to benefit from the treatment but acutely suffered from it. On the other hand, cancer is usually an aggressive disease, and requires aggressive therapy to have a chance to cure it. We (often) do not know in advance who will benefit from aggressive treatment and who will not. We tend to give the benefit of the doubt in prescribing aggressive therapy. Even comfort care may have unanticipated side effects which distress the patient, and all care needs to be fine-tuned to maximally benefit each patient .
The third category is problems caused by psychological or emotional reactions to the cancer or it’s treatment, often leading to actual physical symptoms (“somatization”) . This is normal for may patients, and is just as real to them as if the symptom(s) had a physical cause . Examples are intense nausea immediately before chemotherapy, severe depression, pain beyond that explainable by the physical cancer, and perhaps some of the cases of pain within phantom limbs (ones that had been previously amputated). These symptoms demand treatment just as though they had “actual” causes, albeit the treatment may be different. The fact is the symptom may have an unrecognized physical cause, or excellent explanation. No patient should have their symptom(s) arbitrarily dismissed by the doctor. This is because “symptoms” are what the patient feels– which is inarguable . On the other hand “signs” (e.g. fever, weight loss, blood pressure) can be measured and confirmed. With increasing diagnostic technology, previous “symptoms” (i.e. abdominal pain) may now be found to have a “sign” (i.e. tumor spread) causing it. Modern psychiatrists are taught to obviate(“rule-out”) physical disease (e.g. pancreas cancer) in patients with new onset depression, by referring them to appropriate doctors.
Additionally, there is the fact that cancer may make worse(“exacerbate”) other unrelated medical conditions, such as a weak heart, diabetes or arthritis. Also, the social, emotional and financial hardships of cancer and it’s therapy must be individually addressed for each patient, by competent and caring professionals.
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