Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 24: Cancer and Growths (introduction...) Cancer (introduction...) Causes of cancer Finding and treating cancer early Problems of the Cervix (the Opening of the Womb) Common problems of the cervix Cancer of the cervix Problems of the Womb Common growths of the womb Cancer of the womb (cancer of the uterus, endometrial cancer) Problems of the Breasts (introduction...) Cancer of the breast Problems of the Ovaries Cysts on the ovaries Cancer of the ovaries Other Common Cancers Lung cancer Mouth and throat cancer Cancer of the liver Cancer of the stomach When Cancer Cannot Be Cured Working for Change

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 24: Cancer and Growths

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Cancer is a serious sickness that can affect many different parts of the body. If it is treated early it is often curable, but if left too long it can cause death. Many people who get cancer die from it, especially those with little access to health care.

Women often do not see a health worker or doctor unless they are very sick. So women who get cancer are more likely to get very sick or die because the cancer is not found early enough. Also, women who get cancer are sometimes considered ‘cursed’ and may be shunned by their families or communities. This isolation is not only bad for the women who are sick, but also for the whole community, since it keeps everyone from knowing about how cancer makes people sick.

WHAT IS CANCER?

All living things, like the human body, are made up of tiny cells that are too small to see without a microscope. Sometimes these cells change and grow in an abnormal way, causing growths (tumors). Some growths go away without treatment. But some growths get larger or spread and may cause health problems. Most growths do not become cancer, but some do.

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Cancer starts when some cells begin to grow out of control and take over parts of the body. When cancer is found early, it can often be removed by surgery, or treated with medicines or radiation, and the chance of it being cured may be good. Once cancer spreads, however, curing it is more difficult and eventually becomes impossible.

¨ ‘Tumor’ is another word for growth or swelling. Some tumors are cancer and some are not.

Cancer

Cancer of the cervix, breast, and womb are the most common ‘women’s’ cancers. Other common cancers that both men and women get are cancer of the lung, colon, liver, stomach, mouth, and skin.

Causes of cancer

The direct causes of most cancers are not known. But these things may make you more likely to get cancer:

· smoking tobacco, which is known to cause lung cancer, and also increases the risk of getting most other cancers

· certain viral infections, like hepatitis B or genital warts

· eating foods with too much fat or with harmful chemicals

· using some medicines, like hormones, incorrectly

· working with or living around certain chemicals (like pesticides, dyes, paints, and solvents)

· living or working near nuclear power plants

Also, if others in a woman’s family (blood relatives) have had a certain kind of cancer, this may mean she is more likely to get that same kind of cancer (this is called a hereditary risk).

¨ Cancer is not an infection. It is not ‘catching’ and cannot spread from one person to another.

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Healthy living can prevent many cancers. This means eating nutritious food and avoiding things that may cause cancer. For example:

· Do not smoke or chew tobacco.

· Try to avoid harmful chemicals in your home or workplace, including foods grown or preserved with them.

· Protect yourself from sexually transmitted diseases (STDs).

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Finding and treating cancer early

Finding cancer early can often save a woman’s life, because she can get early treatment, before the cancer spreads. Some cancers have warning signs that show something may be wrong. But usually, to find out if you have cancer, you must have a test that takes a few cells from the part of your body where the cancer may be. Then the cells must be examined with a microscope, by someone who is trained to recognize cancer

Cancer cells are so small, you need a microscope to see them.

Cancers that do not have early signs can often be found with screening tests, routine tests given to people to see if everything is normal. A Pap test for cancer of the cervix is one kind of screening test.

If you have warning signs, or a test shows something may be wrong, do not wait. Follow the advice in this chapter for finding and treating the problem as soon as possible.

Problems of the Cervix (the Opening of the Womb)

Common problems of the cervix

Nabothian cysts are small blisters or bumps on the cervix that are filled with fluid. There are no signs, but they can be seen during a pelvic exam (with a speculum). These cysts are harmless, so no treatment is needed.

Nabothian cysts on the cervix

Polyps are dark red growths, sometimes found at the cervix. They also grow inside the womb. For more about them, see ‘Common Growths of the Womb’.

Inflammation of the cervix. Many infections of the vagina - like trichomonas - and some STDs affect the cervix, and can cause growths, sores, or irritation and bleeding after sex. For information about those types of problems, including treatment, see the chapter on “Sexually Transmitted Diseases and Other Infections of the Genitals.”

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Cancer of the cervix

Cancer of the cervix is the most common cancer in the less-developed world. The main cause is a virus - human papilloma virus, or HPV - which is the same virus that causes genital warts. This cancer grows slowly for about 10 years, and if it is treated early it can be completely cured. But many women die every year from cancer of the cervix because they never knew they had it.

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A woman is at greater risk of getting cancer of the cervix if she:

· is older than 35.
· began to have sex at a young age (within only a few years of starting her monthly bleeding).
· has had many sex partners, or has a partner who has had many sex partners.
· has had frequent STDs, especially genital warts.
· has HIV/AIDS.
· smokes tobacco.

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Warning signs:

There are usually no outward signs of cancer of the cervix until it has spread and is more difficult to treat. (There are often early signs on the cervix, which can be seen during a pelvic exam. This is why regular exams are so important.)

Abnormal bleeding from the vagina, including bleeding after sex, or an abnormal discharge or bad smell from the vagina can all be signs of a serious problem, including advanced cancer of the cervix. If you have any of those signs, try to get a pelvic exam and a Pap test.

IMPORTANT
If you are treated with medicines for a vaginal discharge and do not get better, you should try to have your cervix examined and get a Pap test to look for cancer.

Finding and treating cancer of the cervix

Because cancer of the cervix does not have early warning signs, but can be cured if it is found early, it is good to be tested for it regularly, if possible. The tests are designed to look for abnormal tissue on the cervix. Such tissue may be slightly abnormal (mild dysplasia), more abnormal (severe dysplasia), or early cancer (before it has spread).

¨ If you are a health worker, try to get training in testing for cervical cancer. Encourage your community to offer cancer screening.

The Pap test

The most common test is the Pap test. For this test, a health worker scrapes some cells from the cervix (this is not painful) during a pelvic exam and sends them to a laboratory to be examined with a microscope. When you have this test, you must return for the results, usually after several weeks.

Visual inspection

A new, low-cost method of screening women for cancer of the cervix uses a vinegar solution (acetic acid) which is painted on the cervix, and turns abnormal tissue white. The cervix is examined, sometimes with the aid of a small lens that makes it easier to see. If a woman has abnormal tissue, she may need other tests or treatment.

Regular testing for cancer of the cervix can save many lives.

Other tests used to find cancer

· Biopsy. A piece of tissue is taken from the cervix and sent to a laboratory to be examined for cancer cells.

· Colposcopy. This tool, available in some hospitals, magnifies the cervix (makes it look bigger) so it is easier to see signs of cancer

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How often women should be tested To find cancer of the cervix early enough to treat it simply and successfully, women should be tested at least every 3 years. In places where this is not possible, women should try to get tested at least every 5 years, especially women over 35. You should be tested more often, if possible, when: · you are more at risk for developing cancer of the cervix. · you have a Pap test that shows some slightly abnormal cells. These cells often do not become cancer, and they return to normal in 2 to 3 years. But since those cells could be early signs of cancer, you should have another Pap test in 1 to 2 years to make sure cancer is not growing.

Treatment:

If a test shows that you have severe dysplasia or a more advanced cancer, you will need treatment You and your doctor should decide together what treatment is best. Treatment in the early stages can be simple, using methods that remove or destroy the cancer tissue.

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In some places a method called cryotherapy is available, which freezes the cervix and kills the cancer. Another treatment is to remove part of the cervix (cone biopsy). If it is available, this treatment may be best if you still want to have children and the cancer has not spread, because you can keep your womb. When cancer is found and treated before it spreads, it can be cured.

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¨ You may need to go to a large, special hospital for cancer treatment.

If the cancer is found after it has grown for a long time, it may have spread beyond the cervix to other parts of the body. In this case you will usually need surgery to remove both the cervix and womb (hysterectomy). Sometimes radiation therapy can help.

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Deaths from cancer of the cervix can be prevented

When people do not know about the risks for cancer of the cervix and how finding it early can prevent death, more women die. To change this, we can:

· learn what increases a woman’s risk, and work together on finding ways to reduce these risks. It is especially important for girls to be able to wait until they are grown women before having sex. All women also need to be able to protect themselves from STDs.

· learn about cancer screening. Finding cancer of the cervix early can save lives.

In some parts of the world Pap tests are available to women who live near hospitals. Other women are able to get Pap tests from clinics that offer maternal and child health services, family planning, and treatment for STDs.

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Developing screening programs may seem too costly but it is cheaper than treatment. Screening programs can help the most women while costing the least if they:

· target older women. Young women can also get cancer of the cervix, but women over 35 are most at risk.

· test as many women as possible, even if this means testing them less often. Testing all women at risk every 5 to 10 years will find many more cancers than testing only some women more often.

· train local health workers in how to give Pap tests and do visual inspection.

Problems of the Womb

Common growths of the womb

Fibroid tumors

Fibroids are growths of the womb. They can cause abnormal bleeding from the vagina, pain in the lower belly, and repeated miscarriage (losing a pregnancy). They are almost never cancer.

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Signs:

· heavy monthly bleeding or bleeding at unusual times of the month
· pain or a heavy feeling in the lower belly
· deep pain during sex

Finding and treating fibroids

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Fibroids are usually found during a pelvic exam. The womb will feel too large or be the wrong shape. A test called an ultrasound, if it is available, can show how large the fibroids are.

An ultrasound test can show how large fibroids are.

If fibroids cause problems, they can be removed with surgery. Sometimes the whole womb is removed. But most of the time, surgery is not necessary because fibroids usually become smaller after menopause and stop causing problems. If monthly bleeding is heavy because of fibroids, anemia may develop. Try to eat foods rich in iron.

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Polyps

Polyps are dark red growths that can grow inside the womb or at the I cervix. They are rarely cancer.

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Signs:

· bleeding after sex
· heavy monthly bleeding or bleeding at unusual times of the month

Finding and treating polyps

Polyps at the cervix can be seen and removed easily and painlessly during a pelvic exam by someone who has been trained. To find polyps inside the womb, the inside of the womb must be scraped out (this is called a D and C). The D and C also removes the polyps. The growth is sent to a laboratory to make sure there is no cancer. Once polyps are removed, they usually do not grow back.

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Cancer of the womb (cancer of the uterus, endometrial cancer)

Cancer of the womb usually starts in the lining inside the womb (the endometrium). If it is not treated it can spread to the womb itself and to other parts of the body. This cancer happens most often to women who:

· are over 40 years old, especially if they have gone through menopause.
· are overweight.
· have diabetes.
· have taken the hormone estrogen without also taking progesterone.

Cancer of the womb

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Signs:

· heavy monthly bleeding
· irregular monthly bleeding, or bleeding at unusual times of the month
· bleeding after menopause

IMPORTANT
If you have any bleeding at all, even light spotting, after you have finished menopause (12 months without monthly bleeding), get checked by a health worker to make sure you do not have cancer.

Finding and treating cancer of the womb

To find out if a woman has cancer of the womb, a trained health worker must scrape out the inside of the womb with a D and C, or do a biopsy, and send the tissue to a laboratory to be checked for cancer. If cancer is found, it must be treated as soon as possible with an operation to remove the womb (hysterectomy). Radiation therapy may also be used.

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Hysterectomy Figure In a hysterectomy, sometimes only the womb is removed and sometimes the tubes and ovaries are also removed (total hysterectomy). Since your ovaries make hormones that help protect you against heart disease and weak bones, it is always better to leave them in, if possible. Talk to a doctor about this.

If cancer of the womb is found early, it can be cured. If it is more advanced, curing it is more difficult.

IMPORTANT
Any woman who is over 40 years old and has unusual bleeding should get checked by a health worker.

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Problems of the Breasts

Breast lumps

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Breast lumps are very common in most women, especially soft, fluid-filled ones (called cysts). These usually change during a woman’s monthly cycle, and sometimes feel sore or painful when pressed. Few breast lumps are cancer. But since breast cancer is always a possibility, a woman should try to examine her breasts for lumps once a month (see ‘warning signs’ below).

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Discharge from the nipple

Milky or clear discharge from one or both nipples is usually normal if a woman has breastfed a baby within the last year. Brown, green, or bloody discharge - especially from only one nipple - could be a sign of cancer Get checked by a health worker who can examine your breasts.

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Breast infection

If a woman is breastfeeding a baby and gets a hot, red sore area on the breast, she probably has mastitis, or an abscess. This is not cancer and is easily cured. If the woman is not breastfeeding, it may be a sign of cancer

Figure

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Cancer of the breast

Breast cancer usually grows slowly. If it is found early, it can sometimes be cured. It is hard to tell who will get breast cancer. The risk might be greater for a woman whose mother or sisters have had breast cancer, or for a woman who has had cancer of the womb. Breast cancer is more common in women over age 50.

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Warning signs:

· a hard painless lump with a jagged shape, that is in only one breast and does not move under the skin

· redness, or a sore on the breast that does not heal

· skin on the breast that is pulled in, or looks rough and pitted, like orange or lemon peel

· a nipple that is pulled inward

· abnormal discharge from a nipple

· sometimes, a painful swelling under the arm

· rarely, pain in the breast

If there is one or more of these signs, get help from a trained health worker right away.

Finding and treating breast cancer

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If you examine your breasts regularly, you are likely to notice if there are any changes or if a new lump develops. A special X-ray called a mammogram can find a breast lump when it is very small and less dangerous. But mammograms are not available in many places, and they are very expensive. And it cannot tell for sure if a lump is cancer.

The only way to know for sure that a woman has breast cancer is with a biopsy. For this, a surgeon removes all or part of the lump with a needle or a knife and has it tested for cancer in a laboratory.

Treatment depends on how advanced the cancer is and what is available where you live. If a lump is small and found early, just removing the lump may be effective. But for some cases of breast cancer, an operation may be needed to remove the whole breast Sometimes doctors also use medicines and radiation therapy.

No one knows yet how to prevent breast cancer. But we do know that finding and treating breast cancer early makes a cure more likely. For some women it never comes back. In other women, the cancer may come back years later. It may come back in the other breast or, less often, in other parts of the body.

¨ See a health worker right away if you have already had breast cancer and find another lump in the breast or notice other warning signs of cancer.

Problems of the Ovaries

Cysts on the ovaries

These cysts are fluid-filled sacks that women can get on their ovaries. They happen only during the reproductive years, between puberty and menopause. A cyst can cause pain on one side of the lower abdomen and irregular monthly bleeding. But most women only find out they have a cyst if a health worker feels one during a pelvic examination.

Cyst

Most cysts last only a few months and go away on their own. But some can grow very large and must be removed by surgery. If you have severe pain, see a health worker right away.

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Cancer of the ovaries

Cancer of the ovaries is not common. There are usually no warning signs, but a health worker might feel an ovary that is very large while doing a pelvic examination. Surgery, medicines, and radiation therapy are all used for treatment, and cure is very difficult.

Other Common Cancers

Lung cancer

Lung cancer is a growing problem that is often caused by smoking tobacco. It is more common in men because they usually smoke more than women. But because many women now smoke as much as men, they are starting to get more lung cancer. In some countries, more women now die from lung cancer caused by smoking than from any other kind of cancer. And in many places, girls are starting to smoke as early and as much as boys. As more girls and women smoke, even more women will end up getting lung cancer.

Lung cancer does not usually affect people until they are over 40 years old. If a woman stops smoking, her risk of getting lung cancer becomes much less. The signs (coughing up blood, losing weight, difficulty breathing) appear when the cancer is advanced and difficult to cure. Surgery to remove part of the lung, medicines, and radiation therapy are all used to treat lung cancer.

Smoking causes cancer.

¨ The signs of lung cancer are the same as tuberculosis (TB). Seek medical help if you have these signs.

Mouth and throat cancer

Mouth and throat cancer can be caused by smoking and chewing tobacco. If you smoke or chew tobacco, and have sores in your mouth that do not heal, get medical advice.

Cancer of the liver

Some people who become infected with hepatitis B develop cancer of the liver years later. Signs of liver cancer are a swollen abdomen and general weakness. See a health worker if you think you may have liver cancer.

Hepatitis B can be prevented by having safer sex and by getting vaccinated. Babies can be protected against hepatitis B by vaccination at birth. Adults can be vaccinated at any time.

Cancer of the liver can be caused by hepatitis B.

¨ Try to make hepatitis B vaccine available in your community.

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Cancer of the stomach

Cancer of the stomach can occur in women and men over age 40. Usually there are no signs until it is advanced. Surgery is the only treatment and may not be successful.

When Cancer Cannot Be Cured

Many cancers can be cured, but others cannot, especially if the cancer has spread to several parts of the body. Also, hospitals that treat cancer are often far away, in large cities, and treatment is costly.

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Sometimes, when cancer is found late, there is no cure. Then it may be best to stay at home in the care of your family. This time can be very difficult. Eat as well as you can and get enough rest. Medicines for pain, anxiety, and sleeping problems can make you more comfortable. Talking with someone close to you can help you prepare for death, and help you plan for your family’s future after you are gone.

Working for Change

Many unnecessary deaths from cancer could be prevented if more cancers were found and treated earlier. To help make this happen, organize women and men to promote:

· better cancer screening in local health services and rural areas.

· training for local health workers to do visual inspection for cancer of the cervix, Pap tests, and breast exams.

· more labs and trained technicians to read Pap tests.

· better education and more community awareness about how cancer can be prevented, who is at risk, what the warning signs are, and the benefits of cancer screening.

· lower cost care for women who have cancer.

It is also important for women to:

· learn to do breast self-examinations.
· know the signs of cancer especially cancer of the womb, breast, and cervix.

When people in the community know more about the things that are likely to cause cancer, they may be better able to avoid them. This could prevent many cancers from starting. Help people in your community learn that they can prevent many unnecessary deaths from cancer if they avoid smoking or chewing tobacco, and if women are able to protect themselves from STDs.