“You Have Cancer”

by Dr. Marel Ver

The sentence “You have cancer” is one of the most devastating sentences a person can hear.

Even more disturbing is when the diagnosis is from work-up or treatment of something that may be a minor concern or from what appears like a completely different issue.

As a general surgeon taking emergency on-call in West Oahu, I see an unfortunate amount of hepatobiliary (pancreas, liver, gallbladder), stomach, ovarian/uterine cancers, and even lymphomas presenting to the emergency room with bowel/abdominal problems.

They often present with complaints of pain, bleeding, and/or intestinal blockages/obstruction. These patients have symptoms because the cancers have grown large enough to change normal anatomy. Sometimes, the cancers compress or sit on other organs, causing problems.

My priority as the surgery consultant is to manage the presenting problem and then work backwards to figure out the cause. Work-ups aimed at diagnosing exactly what is happening can include imaging, labs, biopsies, endoscopies, and even surgery.

In my outpatient clinic, I also see a fair amount of lumps and bumps that occasionally end up being lymphoma, skin, thyroid, or metastatic cancers.

Sometimes cancers like kidney cancers are only seen as an incidental finding on a CT scan for something else. Like the in-hospital problems, work-ups will often include a lot of testing.

Symptomatic cancers are often large in size or have spread to other organs, which makes them late-stage cancers.

The most widely used cancer staging system is the TNM system. The T refers to the primary (main) tumor size. The N refers to the number of lymph nodes that the cancer spread to. The M refers to whether the cancer has metastasized or spread to other parts of the body.

There are different TNM stages for each type of cancer. In general, the higher the stage, the larger and more spread the tumor is. Stage IV cancer is metastatic cancer, in which the cancer has spread to other parts of the body.

A person’s life expectancy decreases as the stage increases. In general, Stage 0 and earlier-stage cancers are potentially curable. Life expectancy 5 years after diagnosis is significantly decreased in stage IV cancers.

As per the National Comprehensive Cancer Network (NCCN) guidelines, treatments may vary substantially due to the type of cancer and identified stage at work-up. Main cancer therapy options include surgery, chemotherapy, and radiation.

In late-stage cancers, unfortunately, surgery for the cure of the cancer may not be an option.

However, surgery and other procedures may be offered for palliative or symptom management, aiming to improve the quality and/or length of life as the patient continues to live with cancer.

The University of Hawaii Cancer Center and the Hawaii Department of Health collect data for the Hawaii Tumor Registry. This registry was established in 1960.

Since 2018, more than 7,000 Hawaii residents have been diagnosed with invasive cancer yearly, with more than 2,000 cancer deaths. Cancer is the number two cause of death in Hawaii (20.1% in 2021), just behind heart disease (20.9%). Nearly 67,000 Hawaii residents are cancer survivors.

Much like the rest of the United States, breast, prostate, and colon cancer are the most frequent cancers. However, Hawaii has a higher incidence of stomach, liver, and bile duct cancer compared to the mainland.

Thyroid cancers are more common in Filipino females. Native Hawaiian females have the highest lung cancer incidence and mortality rates. Lung cancer is the leading cause of death in the state overall. Whites have the highest rates of melanoma due to the effects of sun exposure on their non-pigmented skin.

Of note, in darker-skinned people, melanoma can be missed on the palms, soles of the feet, and in the web spaces between fingers and toes.

West Oahu surgical oncologist Dr. Christina Wai reports that in her practice, she has a high volume of colorectal cancer. There are occasional pancreatic cancers.

Biliary and gallbladder cancers are rare. In general, only about 10-15% of pancreatic cancers are operable at the time of diagnosis.

Interventional endoscopist Dr. Aaron Small helps to treat late-stage cancer patients.

When appropriate, he offers endoscopic stents and drainage procedures for the intestines for the purpose of relieving pain and suffering and allowing for simple joys, like eating and being able to stay home with family.

A diagnosis of cancer, and notably a late-stage cancer, is life-changing and scary for the patient and family. As a patient, learn about your disease and your treatment options.

Know the risks and benefits of doing something versus doing nothing. Sometimes medical treatments like chemotherapy can be physically overwhelming and can affect quality of life.

Fortunately, many current cancer treatments are more effective and more tolerable as research and science advance. Inquire about clinical trials. Lean on family and friends, if available, for support.

I must mention not be afraid to request a language interpreter. Many patients understand and can communicate in simple English, but an interpreter may be more helpful for challenging conversations where the details matter.

Patients often decline interpreter services because they are embarrassed and fear being viewed as less educated. Interpreter services are often free services, so don’t be ashamed or hesitate to have an interpreter as an extra resource in the room.

The last thing you want is to misunderstand important information that may impact your life.

My colleagues and I agree that there are only a few cancers that we can really prevent, and thus stress the importance of screening. Anecdotally, in our practices, Filipinos are hesitant to complete screening tests due to work, family, or time constraints, but especially since “nothing is bothering them” and the fear of “finding a problem.”

Screening tests are often simple medical tests performed to detect health conditions early so that the disease can be prevented or treated more easily.

We recommend screening tests per NCCN guidelines for breast, colon, prostate, and lung cancers, as they are the most common new cancer cases in the US and in Hawaii.

Screening tests have minimum age recommendations for “average risk” patients who have no personal history or family history of health conditions related to cancer.

If a person has “increased risk,” like having a family history of the specific cancer, a history of cigar or cigarette smoking, or having other specific related health conditions, then we may have to start screening earlier.

Screening for breast cancer for the average risk woman (no family history of breast cancer) starts at 40 years old with a mammogram. The age for screening for colon cancer has now decreased to 45 years old. Colon cancer screening can be performed with colonoscopy, stool sampling, blood tests, or imaging.

Colonoscopies are the most invasive but provide the most information. Screening for prostate cancer starts at 45 years old with a blood test and rectal exam. A CT scan for lung cancer screening is recommended for patients over 50 years old who have been smoking for >20 years (or 20 pack years).

Screening for cervical cancer (caused by the human papillomavirus) depends on age and health history, but generally starts with a Pap test at 21 years old. Fortunately, the HPV vaccination (Gardasil 9) available for adolescents and adults helps to prevent HPV cancers in males and females later in life.

However, for uncommon or rare cancers, screening tests are not routinely recommended. Therefore, it is very important to pay attention to your own body.

Growing cancers are hypermetabolic and use up a lot of the body’s energy. This can lead to generalized symptoms like weakness, poor appetite, and unintentional weight loss.

Go to your doctor for these concerns or other symptoms like pain, bleeding, or a new lump. Screening body CT scans or MRIs are generally not recommended (nor covered by insurance), but specific imaging can be ordered if there is a medical indication.

Medical oncologist Dr. Mel Palalay stresses the importance of knowing your risks, which include your family history, race, and social/environmental factors.

He wants patients to strongly advocate for themselves to their PCP, especially if symptoms persist. Obtain second opinions as necessary.

In addition, my advice is to be physically and mentally healthy. Be positive. Don’t take time for granted. I previously wrote an article Ensuring a Meaningful Life (HFC Sept 16 2023), addressing the importance of advanced care planning with your family.

Cancer not just affects the patient, but also the whole family. Emotions will run high and all over the place for everyone. This is okay and expected.

If you have a loved one with cancer, be there for their support. Being a caregiver is tough. It’s okay to seek support, too.

Lastly, take control of your health as it affects your life. The Healthy Hawaii Strategic Plan 2030 makes simple recommendations to prevent cancer.

Stop smoking/vaping. Limit alcohol. Protect/limit your exposure to UV sunlight, radiation, and chemicals. Protect yourself from some viruses and bacteria by taking vaccinations when recommended, using protection during sex, and treating infections in the body. Eat a well-rounded diet, stay active, and avoid obesity.

I’d like to acknowledge and thank my Hawaii colleagues cited in this article and those who helped me put this together.

DR. MAREL VER is a board-certified general surgeon practicing in Oahu and a past PMAH president. Her wide range of practice exposes her to important issues that inspire her to write to empower the community.