Bile duct cancer (cholangiocarcinoma)

• Bile duct cancer
• Causes and risk factors
• Signs and symptoms
• How it is diagnosed
• Laparotomy
• Staging and grading
• Treatment overview
• Surgery
• Stent insertion
• Other treatments
• Clinical trials
• Your feelings
• References

Bile duct cancer

Cancers of the bile duct are rare in the Western world. There are approximately 600 people diagnosed with cholangiocarcinomas each year in the UK.

The bile ducts are the tubes connecting the liver and gall bladder to the small intestine (small bowel). Bile is a fluid made by the liver and stored in the gall bladder. Its main function is to break down fats during their digestion in the small bowel. In people who have had their gall bladder removed, bile flows directly into the small intestine. The bile ducts and gall bladder are known as the biliary system.

Diagram showing the position of the bile duct

Cancer is classified according to the type of cell from which it starts. Cancer of the biliary system almost always starts in a type of tissue called glandular tissue and is then known as adenocarcinoma.

If the cancer starts in the part of the bile ducts contained within the liver it is known as intra-hepatic. If it starts in the area of the bile ducts outside the liver it is known as extra-hepatic. This information concentrates mainly on extra-hepatic bile duct cancers. Intra-hepatic bile duct cancers may be treated like primary liver cancer.

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Causes and risk factors

The cause of most bile duct cancers is unknown. There are a number of risk factors that can increase your risk of developing bile duct cancer. These are:

Inflammatory bowel disease People who have a chronic inflammatory bowel condition, known as ulcerative colitis, are at an increased risk of developing this type of cancer.

Abnormal bile ducts People who are born with (congenital) abnormalities of the bile ducts, such as choledochal cysts, are more at risk of developing cholangiocarcinoma.

Infection In Africa and Asia, infection with a parasite known as the liver fluke is thought to cause a large number of bile duct cancers.

Bile duct cancer, like other cancers, is not infectious and cannot be passed on to other people.

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Signs and symptoms

If cancer develops in the bile ducts it may block the flow of bile from the liver to the intestine. This causes the bile to flow back into the blood and body tissues, and leads to the skin and whites of the eyes becoming yellow (known as jaundice). The urine also becomes a dark yellow colour and stools (bowel motions) are pale. The skin may become itchy. Mild discomfort in the abdomen, loss of appetite, high temperatures (fevers) and weight loss may also occur.

These symptoms can be caused by many things other than bile duct cancer, but any jaundice or any symptoms which get worse or last for a few weeks should always be checked by your doctor.

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How it is diagnosed

Usually you begin by seeing your GP, who will examine you. They will refer you to a hospital specialist for any tests that may be necessary and for expert advice and treatment.

At the hospital the doctor will ask you about your general health and any previous medical problems. They will also examine you and take blood samples to check your general health and that your liver is working properly.

The following tests are commonly used to diagnose bile duct cancer:

Ultrasound scan Sound waves are used to make up a picture of the bile ducts and surrounding organs. These scans are done in the hospital's scanning department. You will be asked not to eat, and to drink clear fluids only (nothing fizzy or milky) for four to six hours before the scan. Once you are lying comfortably on your back, a gel is spread onto your abdomen. A small device, like a microphone, is then rubbed over the area. The sound waves are converted into a picture using a computer. The test is completely painless and takes 15–20 minutes.

CT (computerised tomography) scan A CT scan takes a series of x-rays which are fed into a computer to build up a detailed picture of your bile ducts and surrounding organs. On the day of the scan you will be asked not to eat or drink anything for at least four hours before your appointment. You will be given a special liquid to drink an hour before the test and again immediately before the scan. The liquid shows up on x-ray to ensure that a clear picture is obtained.

Once you are comfortably positioned on your back on the couch, the scan can be taken. About half-way through the scan a special dye will be injected into the vein to show up the blood vessels. This may make you feel warm or 'flushed' for up to half an hour. The test itself is completely painless, but it will mean that you have to lie still for about 10–30 minutes. If you had little to drink before the scan, you may be advised to drink plenty afterwards to make up for this.

MRI (magnetic resonance imaging) scan This test is similar to a CT scan, but uses magnetism instead of x-rays to build up cross-sectional pictures of your body. During the test you will be asked to lie very still on a couch inside a large metal cylinder which is open at both ends. The whole test may take up to an hour. It can be slightly uncomfortable and some people feel a bit claustrophobic during the scan, which is also very noisy. You will be given earplugs or headphones to wear. A two-way intercom enables you to talk with the people controlling the scanner.

ERCP (endoscopic retrograde cholangiopancreatography) This is a procedure by which an x-ray picture of the pancreatic duct and of the bile duct can be taken. It may also be used to unblock the bile duct if necessary.

You will be asked not to eat or drink anything for about six hours before the test so that the stomach and duodenum (first part of the small bowel) are empty. You will be given an injection to make you relax (a sedative) and a local anaesthetic spray will be used to numb your throat. The doctor will then pass a thin flexible tube known as an endoscope through your mouth into your stomach and into the duodenum just beyond it. Looking down the endoscope, the doctor can find the opening through which the bile duct and the duct of the pancreas drain into the duodenum. A dye which can be seen on x-ray can be injected into these ducts and the doctor will be able to see whether there is any abnormality or any blockage in the ducts.

If there is a blockage it may be possible or the doctor to insert a small tube known as stent. You may have some discomfort during this procedure; if you do, it is important that you let your doctor know. You will be given antibiotics beforehand (to help prevent any infection) and will probably stay in hospital for one night afterwards.

PTC (percutaneous transhepatic cholangiography) This is another procedure by which your doctor can obtain an x-ray picture of the bile duct. You will be asked not to eat or drink anything for about six hours before the test and will be given a sedative as for the ECRP.

An area on the right side of your abdomen will be numbed with a local anaesthetic (an injection) and a thin needle will be passed into the liver through the skin. A dye will be injected through the needle into the bile duct within the liver. X-rays will then be taken to see if there is any abnormality or blockage of the duct.

You may feel some discomfort as the needle enters the liver. You will be given antibiotics before and after this procedure (to help prevent infection) and you will stay in hospital for at least one night afterwards.

Angiography As the bile duct is very close to the major blood vessels of the liver, a test called an angiogram may be done. The angiogram can check whether the blood vessels are affected by the tumour.

A fine tube is inserted into an artery in your groin and a dye is injected through the tube. The dye circulates in the arteries to make them show up on x-ray. An angiogram is carried out in a room within the x-ray department. Sometimes an MRI scan can be used to show up the blood vessels of the liver and then an angiogram will not be necessary.

Biopsy The results of the previous tests may make your doctor strongly suspect a diagnosis of cancer of the bile duct, but the only way to be sure of the diagnosis is to take some cells or a small piece of tissue from the affected area of the bile duct to look at under a microscope. This is called a biopsy and may be carried out during an ECRP or PTC.

A fine needle is passed into the tumour through the skin after the area has been numbed using a local anaesthetic injection. CT or ultrasound may be used at the same time, to make sure that the biopsy is taken from the right place.

Endoscopic ultrasound scan (EUS) This scan is similar to an ERCP but involves an ultrasound probe being passed down the endoscope to take an ultrasound scan of the pancreas and surrounding structures.

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Laparotomy

If the doctor cannot make the diagnosis from the above tests, a procedure called a laparotomy may be done under a general anaesthetic. This involves making a cut (incision) into your abdomen so that the surgeon can examine the bile duct and the tissue around it for cancer. Sometimes this examination can be done through a tiny cut using a camera called a laparoscope – this procedure is known as keyhole surgery.

If a cancer is found, but looks as though it has not spread to surrounding tissues, the surgeon may be able to remove the cancer or relieve any blockage that it is causing.

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Staging and grading

Staging

The stage of a cancer is a term used to describe its size and whether it has
spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.

Cancer can spread in the body, either in the blood stream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. The system is made up of a network of lymph glands (also known as lymph nodes) that are linked by fine ducts containing lymph fluid. Your doctors will usually look at the lymph nodes close to the biliary system in order to find the stage of your cancer.

• Stage 1A The cancer is contained within the bile duct.
• Stage 1B The cancer has spread through the wall of the bile duct but has not spread into nearby lymph nodes or other structures.
• Stage 2A The cancer has spread into the liver, pancreas or gall bladder or to the nearby blood vessels, but not the lymph nodes.
• Stage 2B The cancer has spread into nearby lymph nodes.
• Stage 3 The cancer is affecting the main blood vessels that take blood to and from the liver, or it has spread into the small or large bowel, the stomach or the abdominal wall. Lymph nodes in the abdomen may also be affected.
• Stage 4 The cancer has spread to distant parts of the body such as the lungs.

If the cancer comes back after initial treatment, this is known as recurrent cancer.

Grading

Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how quickly the cancer may develop. Low-grade means that the cancer cells look very like normal cells; they are usually slow-growing and are less likely to spread. In high-grade tumours the cells look very abnormal, are likely to grow more quickly and are more likely to spread.

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Treatment overview

The type of treatment that you are given will depend on a number of factors, including your general health, the position and size of the cancer in the bile duct and whether the cancer has spread beyond the bile duct.

Consent

Before you have any treatment, your doctor will give you full information about what it involves and explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.

Benefits and disadvantages of treatment

Treatment can be given for different reasons and the potential benefits will vary for each person. If you have been offered treatment that aims to cure your cancer, deciding whether to have the treatment may not be difficult. However, if a cure is not possible and the treatment is to control the cancer for a period of time, it may be more difficult to decide whether or not to go ahead.

If you feel that you can't make a decision about treatment when it is first explained to you, you can always ask for more time to decide.

You are free to choose not to have the treatment and the staff can explain what may happen if you don't have it. You don't have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

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Surgery

Surgery may be used to remove the cancer if it has not spread beyond the bile duct. It is not always possible to carry out surgery, as the bile duct is in a difficult position and it may be impossible to remove the cancer completely. The decision about whether surgery is possible or not depends on the results of the tests described above. If surgery is recommended then you will be referred to a surgeon with a special interest in this rare cancer.

There are different operations depending upon how big the cancer is and whether it has begun to spread into nearby tissues.

Removal of the bile ducts If the cancer is small and contained within the ducts, then just the bile ducts containing the cancer are removed and the remaining ducts in the liver are joined to the small bowel, allowing the bile to flow again.

Partial liver resection If the cancer has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts.

Whipple's If the cancer is larger and has spread into nearby structures, then the bile ducts, part of the stomach, part of the duodenum (small bowel), the pancreas, gall bladder and the surrounding lymph nodes are all removed.

After your operation you may stay in an intensive-care ward for the first couple of days. You will then be moved to a general ward until you recover. Most people need to be in hospital for up to two weeks after this type of operation.

Bypass surgery Sometimes it isn't possible to remove the tumour and other procedures may be performed to relieve the blockage (obstruction) and allow the bile to go into the intestine. The jaundice will then clear up.

The surgical method of dealing with blockage of the bile duct involves joining the gall bladder (or the bile duct) to part of your small bowel. This bypasses the blocked part of the bile duct and allows the bile to flow from the liver into the intestine. This operation is called a cholecysto-jejunostomy or cholecysto-duodenostomy if the gall bladder is used. It is called a hepatico-jejunostomy if the bile duct is used.

Another type of operation may be necessary if the duodenum is also blocked. This is called a gastrojejunostomy and involves connecting a piece of the small bowel (the jejunum) to the stomach to bypass the duodenum. This will stop the persistent vomiting (being sick) that can occasionally happen if the cancer blocks the duodenum.

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Stent insertion

There are two ways in which it may be possible to relieve jaundice without a surgical operation. These use the ERCP or PTC procedures described below.

The ERCP method involves the insertion of a tube, called a stent into the blocked bile duct. The stent is about as thick as a ball-point pen refill and about 5–10cm long (two to four inches). The stent clears a passage through the bile duct to allow the bile to drain away. The preparation and procedure is the same as for ERCP described above. By looking at the x-ray image the doctor will be able to see the narrowing in the bile duct. The narrowing can be stretched using dilators (small inflatable balloons), and the stent can then be inserted through the endoscope to enable the bile to drain.

The tube usually needs to be replaced every three to four months to prevent it becoming blocked. If the tube does block, recurrent high temperatures and/or return of the jaundice will occur. It is important to tell your specialist about these symptoms as early as possible. Antibiotic treatment may be needed and your specialist may advise that the stent is exchanged for a new one. This procedure can be done relatively easily for most people.

During the PTC method, the procedure and the preparation you will need is as described in the section about PTC. A temporary wire is passed to the area of blockage and the stent is guided along the wire. Sometimes a drainage tube (catheter) is left in the bile duct. One end of the catheter is in the bile duct and the other lies outside the body connected to a bag, which collects the bile. This is to help with the insertion of the stent or, sometimes, to enable x-rays to be taken to check the position of the stent after it has been put in place. It is usually left in for a few days. Once the catheter is removed the hole heals over within two days. You will be given antibiotics before and after the procedure to help prevent any infection. It is likely that you will stay in hospital for a few days.

Sometimes, if the bile duct cannot be opened easily from the small intestine during ERCP, a combination of ERCP and PTC may be used.

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Other treatments

Radiotherapy

Radiotherapy is occasionally used to treat bile duct cancer. Radiotherapy treats cancer by using high-energy x-rays to destroy cancer cells while doing as little harm as possible to normal cells. It may be given either externally from a radiotherapy machine, or internally by placing radioactive material close to the tumour.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. They work by disrupting the growth of cancer cells. Occasionally, chemotherapy may be given in combination with radiotherapy for cancers that cannot be removed surgically. Researchers are still looking into how effective chemotherapy is for the treatment of bile duct cancer.

Photodynamic therapy (PDT)

PDT uses a combination of laser light of a specific wavelength and a light-sensitive drug to destroy cancer cells. In bile duct cancer it is used to help relieve symptoms.

The light-sensitive drug (a photosensitising agent) is injected into a vein. It circulates in the bloodstream and enters cells throughout the body. The drug enters more cancer cells than healthy cells. It does not do anything until it is exposed to laser light of a particular wavelength. When a laser is shone on to the cancer, the drug becomes active and destroys the cancer cells.

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Clinical trials

Research into treatments for bile duct cancer is ongoing and advances are being made. Cancer doctors use clinical trials to assess new treatments.

You may be asked to take part in a clinical trial. Your doctor must discuss the treatment with you so that you have a full understanding of the trial and what it means to take part.

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Your feelings

During your diagnosis and treatment you are likely to experience a number of different emotions, from shock and disbelief to fear and anger. At times these emotions can be overwhelming and hard to control. It is quite natural, and important, to be able to express them. Everyone has their own ways of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Others prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

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References

This section has been compiled using information from a number of reliable sources including:

• Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, 2002.
• Gastrointestinal Oncology: Principles and Practice. Kelsen et al. Lippincott Williams and Wilkins, 2002.
• Cancer and Its Management (4th edition). Souhami and Tobias. Oxford Blackwell Scientific Publications, 2003.

For further references, please see the general bibliography.

Anorectal melanoma

This information is about a rare type of cancer called anorectal melanoma (melanoma affecting the anus and/or rectum). You may also find it helpful to read our general information about malignant melanoma.

• What is anorectal melanoma?
• Causes
• Signs and symptoms
• How it is diagnosed
• Staging
• Treatment overview
• Surgery
• Radiotherapy
• Chemotherapy
• Follow-up
• Your feelings
• References

What is anorectal melanoma?

Anorectal melanoma is melanoma affecting the anus and/or rectum. Melanoma is a cancer that develops from cells called melanocytes. Melanocytes produce the pigment melanin, which is responsible for the colour of our skin. These cells are found in many places in our body, including the skin, hair, and lining of the internal organs such as the anus and rectum.

The anorectal area is the third most common site for melanoma after the skin and eye. However, it is still a rare form of cancer, making up less than one in a hundred (1%) of all melanomas and between one to two in a hundred (1–2%) of all anorectal cancers. Anorectal melanoma can occur in several places. These include: the rectum, anal canal (which is the junction between the anus and rectum) and the anus. Most people with anorectal melanoma are aged 60– 80. It is also more common in women.

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Causes

This is a rare type of tumour and, as for many other forms of cancer, the exact cause is unknown. We know that exposure to ultraviolet (UV) rays (either from the sun or sunbeds) increases the risk of developing melanoma of the skin. However, there does not appear to be a link between UV ray exposure and the development of anorectal melanoma.

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Signs and symptoms

A number of these cancers lack the normal dark colouring associated with melanomas and are known as amelanotic. This can make them more difficult to diagnose. People are often treated initially for piles (haemorrhoids). Symptoms include pain, rectal bleeding, a change in bowel habit (diarrhoea or constipation), piles, mucous discharge, tiredness and weight-loss. All of these symptoms can also be caused by many other bowel conditions.

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How it is diagnosed

Usually, you begin by seeing your GP (family doctor) who will do an examination of your back passage.

If your GP thinks that your symptoms could be caused by cancer, or is not sure what the problem is, they will refer you to a hospital specialist. At the hospital, the doctor will take your medical history before doing a physical examination. This will include a rectal examination. To do this, the doctor places a gloved finger into your back passage to feel for any lumps or swellings. This examination may be slightly uncomfortable but it is not painful. The doctor will also check whether or not the lymph nodes in the groin are enlarged. You may then have some of the following tests:

Biopsy A small sample of tissue may be taken from the suspicious area and examined under a microscope. This can be done using a local anaesthetic so that the area is numb. More commonly, excisional biopsies are done. This involves removing the whole tumour.

CT (computerised tomography) scan A CT scan takes a series of x-rays to build a three-dimensional picture of the inside of the body. The scan is painless but takes10–30 minutes. It may be used to see if the cancer has spread to other areas of the body such as the liver, lungs or brain.

MRI (magnetic resonance imaging) scan This type of scanner uses magnetism instead of x-rays to form a series of pictures of the inside of the body. The test can take about 30 minutes. It is completely painless, but some people feel a bit claustrophobic during the scan. It is also noisy and you will be given earplugs or headphones to wear.

Chest x-ray A chest x-ray is usually done to check whether or not the cancer has spread to the lungs.

Blood tests Samples of your blood may be taken to check your general health, the number of cells in your blood (blood count) and to see how well your kidneys and liver are working.

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Staging

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.

Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. The system is made up of a network of lymph nodes (sometimes called lymph glands) that are linked by fine ducts containing lymph fluid.

A commonly used staging system for melanoma is described here:

• Stage 1A: The cancer is less than 0.75mm thick and is localised (has not spread to the lymph nodes
• Stage 1B: The cancer is between 0.76 and 1.5mm thick and is localised
• Stage 2A: The cancer is between 1.5 and 4.0mm thick and is localised
• Stage 2B: The cancer more than 4.0mm thick and is localised
• Stage 3: The cancer has spread to the lymph nodes in the groin and pelvis or to the lymph nodes close to the anus
• Stage 4: The cancer has spread to other parts of the body such as the liver, lungs or brain.

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Treatment overview

A number of different treatments are used for anorectal melanoma, depending on the size and position of the tumour, as well as other factors such as your age and general health. The aim of the treatment is usually to remove all or as much of the cancer as possible. It can also be given to try to destroy any remaining cancer cells and reduce the chance of the cancer returning. Treatment may also be given to relieve symptoms when the cancer has spread to other parts of the body.

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Surgery

There are two main types of surgery that are carried out. These are local resection and abdominoperineal resection.

Local resection This may be used for small tumours on the outside of the anus. This operation removes only the area of the anus containing the cancer cells. The anal sphincter (the muscle in the wall of the anal canal) is not usually affected, and so most people are still able to move their bowels normally. This avoids the need for a colostomy.

Abdominoperitoneal (AP ) resection This is the removal of the anus and rectum. Some of the pelvic and groin lymph nodes are also normally removed. This operation is usually done for:

• large tumours
• tumours which involve the anal sphincter
• tumours that are circling the anus and/or rectum
• tumours that return after local resection.

An AP resection means that you have to have a permanent colostomy. This involves diverting the open end of the bowel on to the surface of the abdomen (tummy area), to allow faeces to be passed out of the body into a colostomy bag. The opening on the abdominal wall is known as a stoma.

Although the idea of a colostomy is often frightening and distressing at first, most people find that they adapt over time. You will be able to get support and advice from the stoma nurse in your hospital. Our nurses can provide you with more information about living with a colostomy.

Occasionally sentinel lymph node biopsy may be offered at the same time as your surgery. This involves a tiny amount of radioactive liquid being injected around the area of the melanoma immediately after it is removed. The lymph nodes close to the melanoma are scanned to see which one has first taken up the radioactive liquid. A blue dye is also injected into the area of the melanoma during the operation. The dye stains the lymph nodes blue. The surgeon removes only the first lymph node that the fluid goes into (the sentinel node), so that it can be tested to see whether it contains melanoma cells.

If the sentinel node contains melanoma cells, all the lymph glands in the area may be removed – this is known as a block dissection. If the sentinel node does not contain melanoma cells, it is very unlikely that the other lymph nodes in the area have been affected by the melanoma and no further treatment is usually needed.

This method of checking the lymph glands is still being researched in trials, to see how effective it is.

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Radiotherapy

Radiotherapy uses high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. In external radiotherapy a beam of radiation is directed at the area of the tumour. The treatment is normally given as small doses (called fractions) over a few days or weeks.

Radiotherapy may be given after a local resection to reduce the risk of the cancer returning. This is known as adjuvant treatment. In this situation, the lymph nodes in the abdomen and groin can also be treated. Additionally, radiotherapy may be given if the cancer returns or as a palliative treatment to control local symptoms.

During the treatment period you may have changes in your bowel function such as diarrhoea or passing wind. These side effects can sometimes be reduced by avoiding particular foods. Towards the end of the treatment period you may have blistering and soreness of the skin around the anal area, and possibly in the groin areas too. Extreme tiredness (or fatigue) is also a common side effect of radiotherapy.

These side effects usually decrease gradually once the treatment has ended, but it may take some months for skin changes to go back to normal. A small number of people find that their bowel function is permanently altered. It is important to discuss this with your doctor as it is often possible to find ways of reducing any problems. Your doctor or a dietitian at the hospital can give you further advice.

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Chemotherapy

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. It may be given after surgery as an adjuvant treatment. It may also be given if surgery is not possible or the cancer returns. The most common chemotherapy drug used is dacarbazine (also known as DTIC).

The chemotherapy drug is usually given by injection into a vein (intravenously). It can temporarily reduce the number of normal cells in your blood. When your blood count is low you are more likely to get an infection and you may tire very easily. During chemotherapy your blood will be tested regularly and, if necessary, you may be given antibiotics to treat any infection. Blood transfusions may be given if you become anaemic due to chemotherapy.

Other side effects may include feeling sick (nausea) and vomiting. Your doctor can prescribe very effective anti-sickness medicines to help control this. Some chemotherapy drugs can also make your mouth sore and cause small mouth ulcers. Rinsing your mouth regularly is important and your nurse can show you how to do this properly. If you don’t feel like eating meals, you can supplement your diet with nutritious drinks or soups. A wide range of drinks is available and you can buy them at most chemists. You can ask your doctor to refer you to a dietitian for advice about your diet.

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Follow-up

After your treatment is completed, you will have regular check-ups and possibly scans or x-rays. You will probably continue to have these tests for several years. If you have any problems, or notice any new symptoms between these times, let your doctor know as soon as possible.

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Your feelings

During diagnosis and treatment for cancer, you are likely to experience different emotions, from shock and disbelief to fear and anger. At times, these emotions can be overwhelming and hard to control. It is quite natural, and important, to be able to express them. Each person has their own way of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

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References

This section has been compiled using information from a number of reliable sources, including:

• Bullard KM et al (2003). Surgical Therapy for Anorectal Cancer Journal of the American College of Surgeons 196 2 206-211
• Droesch JT et al. Wide local excision or abdominoperineal resection as the initial treatment for anorectal melanoma. The American Journal of Surgery 189 4 446-449.
• Kim KB , Sanguino AM et al (2004) Biochemotherapy in Patients with Metastatic Anorectal Mucosal Melanoma. Cancer 100 7 1478-1483.
• Krzysztof B, Nowacki MP and Liszka-Dalecki (1998). Radiation Therapy for Anorectal Melanoma. Acta Oncologica 37 5 497-499.
• Malik A, Hull TL and Floruta C (2004). What is the best surgical treatment for anorectal melanoma. International Journal of Colorectal Disease 19 2 121-123.

For further references, please see the general bibliography.

Anal cancer

The most common type of anal cancer is squamous cell carcinoma. Other rarer types are basal cell carcinoma, adenocarcinoma and melanoma. This information deals with the treatment of squamous cell carcinoma. We also have information on melanoma affecting the anus.

• The anus
• Causes and risk factors of anal cancer
• Signs and symptoms
• How it is diagnosed
• Staging and grading
• Treatment overview
• Radiotherapy
• Chemotherapy
• Surgery
• Relieving symptoms after treatment
• Your feelings
• References

The anus

The anus is the name for the muscular area at the very end of the large bowel.

The anus is the opening of the bowel, and is controlled by a ring of muscle (called a sphincter) that opens and closes to control bowel movements.

Diagram showing the position of the anus

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Causes and risk factors of anal cancer

Cancer of the anus is rare. Less than 800 people are diagnosed with this type of cancer each year in the UK. As with most cancers the cause of anal cancer is unknown. It is slightly more common in women than men. There are a number of factors that can increase your risk of developing anal cancer. These are:

Human papilloma virus (HPV) Anal cancer is more likely to develop in people who have had a particular viral infection called the human papilloma virus (HPV). The risk of having HPV increases with the number of sexual partners you have.

Sexual activity People who have anal intercourse are more likley to develop anal cancer. This may be because they are more likely to have anal HPV.

Lowered immunity Anal cancer is more common in people who have a lowered immunity due to medical conditions, such as HIV.

Smoking Cigarette smoking may increase a person’s risk of developing anal cancer.

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Signs and symptoms

The most common symptoms of anal cancer are pain and bleeding from the
anus. Some people develop small, firm lumps, which may be confused with piles (haemorrhoids).

Other symptoms include discomfort, itching and a discharge of mucous (a
jelly-like substance) from the anus. Faecal incontinence (a reduced ability to control bowel function) may also occur. Anal cancer can appear as an ulcerated area and may spread to the skin of the buttocks.

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How it is diagnosed

Usually you begin by seeing your GP who will examine you and refer you to a specialist in bowel conditions (gastroenterologist).

At the hospital the doctor will ask you about your general health and any previous medical problems. They will also examine you and take blood samples to check your general health and that your liver is working properly. Before the doctor can make a firm diagnosis of anal cancer a number of tests will have to be done.

Rectal examination This is also sometimes known as a PR examination and is where the doctor examines your back passage with a gloved finger.

Biopsy A small sample of cells is taken from the tumour so that it can be examined under a microscope. Usually this involves using either a special biopsy device (known as a punch biopsy) or the doctor can cut a small piece away from the tumour (known as an incisional biopsy). This can be done under local or general anaesthetic.

If the tests show that you have anal cancer, you may need further tests to see if the cancer has begun to spread.

X-rays These may be taken to show if there has been any spread of the cancer.

Ultrasound scan This is a simple scan that uses sound waves to form a picture of the inside of the abdomen. These scans are done in the hospital's scanning department. Once you are lying comfortably on your back, a gel is spread onto your abdomen. A small device is then moved over the area. The sound waves are converted into a picture using a computer. The test is completely painless and takes 15–20 minutes.

You may also have an ultrasound scan known as an endoanal ultrasound. For this scan a small probe is passed into the back passage (rectum), which can show the size and extent of the tumour.

CT (computerised tomography) scan This is a more sophisticated type of x‑ray which builds up a three-dimensional picture of the inside of the body. The scan is painless, but takes longer than a simple x-ray (10–30 minutes). It may be used to identify the exact site of the tumour or to check for any spread of the cancer. Most people who have a CT scan are given a drink or injection to allow particular areas to be seen more clearly. Before having the injection or drink, it is important to tell the person doing this test if you are allergic to iodine or have asthma.

MRI (magnetic resonance imaging) scan This test is similar to a CT scan, but uses magnetic fields instead of x-rays. During the scan you will be asked to lie very still on a couch inside a metal cylinder. You will usually be given an injection to allow the pictures to be seen more clearly.

The test can take about 30 minutes and is completely painless, although the machine is quite noisy. You will be given earplugs or headphones. If you don’t like enclosed spaces you may find the machine claustrophobic. A two-way intercom enables you to talk with the people controlling the scanner.

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Staging and grading

Staging

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.

Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. The system is made up of a network of lymph glands (also known as lymph nodes) that are linked by fine ducts containing lymph fluid. Your doctors will usually check the nearby lymph nodes when staging your cancer.

• Stage 1 The cancer only affects the anus and is smaller than 2cm (¾in) in size. It has not begun to spread into the sphincter muscle.
• Stage 2 The cancer is bigger than 2cm (¾in) in size, but has not spread into nearby lymph nodes or to other parts of the body.
• Stage 3A The cancer has spread to the lymph nodes close to the rectum, or to nearby organs such as the bladder or vagina.
• Stage 3B The cancer has either spread to the lymph nodes in the groin and pelvis, or to the lymph nodes close to the anus, as well as nearby organs such as the bladder or vagina.
• Stage 4 The cancer has spread to lymph nodes in the abdomen or to other parts of the body, such as the liver.

A different staging system called the TNM staging system is sometimes used instead of the number system described above.

• T describes the size of the tumour and whether it has spread into nearby organs.
• N describes whether the cancer has spread to the lymph nodes.
• M describes whether the cancer has spread to another part of the body, such as the liver (secondary or metastatic cancer).

Although this system is more complex, it can give more precise information about the tumour stage.

If the cancer comes back after initial treatment, this is known as recurrent cancer.

Grading

Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how quickly the cancer may develop. Low-grade means that the cancer cells look very like normal cells. They are usually slow-growing and are less likely to spread. In high-grade tumours the cells look very abnormal, are likely to grow more quickly and are more likely to spread.

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Treatment overview

The National Institute for Health and Clinical Excellence (NICE) recommend that people with an anal cancer are treated by a specialist team. Such teams aren't available in all hospitals, so you may have to travel to another hospital for your treatment.

The main type of treatment used for anal cancer is a combination of radiotherapy and chemotherapy, which may be given at the same time (concurrently) or following one another. This combination of treatment is usually very successful. If radiotherapy and chemotherapy are given at the same time, the side effects can be worse.

Surgery may be used, but it is not often the first choice of treatment for anal cancer.

Consent

Before you have any treatment, your doctor will give you full information about what it involves and explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.

Benefits and disadvantages of treatment

Treatment can be given for different reasons and the potential benefits will vary for each person. If you have been offered treatment that aims to cure your cancer, deciding whether to have the treatment may not be difficult. However, if a cure is not possible and the treatment is to control the cancer for a period of time, it may be more difficult to decide whether or not to go ahead.

If you feel that you can't make a decision about treatment when it is first explained to you, you can always ask for more time to decide.

You are free to choose not to have the treatment and the staff can explain what may happen if you do not have it. You don't have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

HIV and treatment

People who have a lowered immunity because of HIV, as well as having anal cancer, may get more side effects during and after treatment. As a result, the amount of radiotherapy and dosages of chemotherapy may be reduced. Your specialist can give you more information.

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Radiotherapy

Radiotherapy is the use of high-energy rays to destroy cancer cells, while doing as little harm as possible to normal cells. The treatment is often given for a few minutes each weekday for between 4–6 weeks.

During the treatment period you may have changes in how your bowel works such as diarrhoea, or passing wind: these side effects can sometimes be reduced by avoiding particular foods. Towards the end of the treatment period you may have blistering and soreness of the skin around the anal area, and possibly in the groin areas too. Extreme tiredness, or fatigue, is also a common side effect of radiotherapy for anal cancer.

These side effects usually decrease gradually once the treatment has ended, but it may take some months for skin changes to go back to normal. A few people find that the way their bowel works is permanently altered. It is important to discuss this with your doctor or specialist nurse as it is often possible to find ways of reducing any problems. Your doctor or a dietitian at the hospital can give you further advice.

Other potential side effects that can occur after radiotherapy for anal cancer include narrowing of the vagina (vaginal stenosis), and vaginal dryness. To help prevent this, women will be asked to use a vaginal dilator with a lubricating jelly to keep the vaginal walls open and supple. Some women may also need to use lubricating jelly during sexual intercourse.

Infertility (loss of the ability to have children) can also be a side effect of radiotherapy. If you are concerned about your risks of being infertile following treatment, it is a good idea to discuss this issue with your specialist before starting treatment.

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Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The chemotherapy drugs are usually given by injection into a vein (intravenously).

Chemotherapy can temporarily reduce the number of normal cells in your blood. When your white blood cell count is low you are more likely to get an infection; if your red blood cell count is low (anaemia) you may tire very quickly; and if the number of platelets is low you may bruise more easily. During chemotherapy your blood will be tested regularly and, if necessary, you may be given antibiotics to treat any infection. Blood transfusions may be given if you become anaemic due to chemotherapy.

Other side effects may include feeling sick (nausea) and being sick (vomiting). Some chemotherapy drugs can also make your mouth sore and cause small mouth ulcers. Regular mouthwashes are important and your nurse will show you how to use these properly.

If you don’t feel like eating meals, you can supplement your diet with nutritious drinks or soups. A wide range of drinks are available and you can buy them at most chemists. You can ask your doctor to refer you to a dietitian for advice about your diet.

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Surgery

Surgery may be used if your initial treatment does not completely get rid of the cancer, or if there are signs that your cancer has returned. There are two main types of surgery: local resection and abdominoperineal resection.

Local resection This may be used for small tumours on the outside of the anus. This operation only removes the area of the anus containing the cancer cells. The anal sphincter is not usually affected, and so how their bowel works remains the same for most people.

Abdominoperineal resection This is the removal of the anus and rectum. This operation requires a permanent colostomy, which involves diverting the open end of the bowel on to the surface of the abdomen (tummy area), to allow faeces to be passed out of the body into a colostomy bag. The opening on the abdominal wall is known as a stoma.

Although the idea of a colostomy is initially frightening and distressing for many people, most people find that they adapt over time and can return to normal activities. You will be able to get support and advice from the stoma nurse in your hospital. Our nurses can send you information about having a colostomy.

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Relieving symptoms after treatment

It is not unusual for people to find that they have distressing side effects for a time following treatment for anal cancer. Some people find that they have diarrhoea and occasional incontinence, as well as a feeling of bloatedness and wind. These symptoms are usually temporary but may last for several months.

It may help to discuss your symptoms with your doctor, nurse or a dietitian. They should be able to give you further advice about how to manage any problems.

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Your feelings

During your diagnosis and treatment you are likely to experience a number of different emotions, from shock and disbelief to fear and anger. At times these emotions can be overwhelming and hard to control. It is quite natural, and important, to be able to express them. Everyone has their own ways of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Others prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

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References

This section has been compiled using information from a number of reliable sources, including:

• Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, 2002.
• Gastrointestinal Oncology: Principles and Practice. Kelsen et al. Lippincott Williams and Wilkins, 2002.
• The Textbook of Uncommon Cancers (3rd edition). Raghavan et al. Wiley, 2006.

For further references, please see the general bibliography.

Understanding cancer terms and statistics

A cancer diagnosis often comes with a great deal of new information. As well as coping with the diagnosis there are a lot of new terms and statistics to understand. It is never easy.

In this section there are a number of question and answers to help you understand some of the terms that may be used.

It is fairly common for information about cancer to include statistics. Your doctors or nurses may use statistics, for example, to give you an idea how effective a treatment might be, or how likely you are to get a particular side effect from the treatment. Statistics can help us to make decisions about which treatments to have. However, unless your work involves dealing with statistics, you may have difficulty understanding what they mean.

Statistics is a way of presenting information in numbers. It is important to remember that statistics are usaully based on large numbers of people, who have taken part in cancer research trials. The statistics can't tell you what is going to happen for an individual person, although they can give you some idea and tell you what the 'chances are' of something happening, or not happening.

If you don't understand the statistics you have been given, ask your doctor or nurse to explain them again, possibly in a different way. You could also discuss them with one of the nurses on our cancer information service.

If you are looking for information about cancer statistics, Cancer Research UK have very detailed information about the incidence of cancer. All of their information about statistics is aimed at health professionals.

Why do cancers come back?

In some cases cancer can come back after treatment. It may come back in the same area in which it first started, this is known as a recurrence. This can happen because tiny cancer cells, that may have been left behind when the tumour was removed, or that weren't destroyed by treatments such as radiotherapy and chemotherapy, have begun to divide again and form a tumour.

Or it may develop in a different part of the body, often referred to as a metastasis or secondary cancer. This can happen because a cancerous (malignant) tumour consists of cancer cells which have the ability to spread beyond the original site. If left untreated they may invade and destroy surrounding tissues. Sometimes cells break away from the original (primary) cancer and spread to other organs in the body by travelling in the bloodstream or lymphatic system. When these cells reach a new area of the body they may go on dividing and form a new tumour.

How is it treated?

There are six main types of treatment for cancer and these are described below. It is fairly common for a combination of treatments to be used.

Active surveillance (or watchful waiting)

Some types of cancer grow very slowly and may cause no problems for many years. In this situation you may not need to have any treatment for some time, but your doctor will monitor you closely so that if the cancer does start to grow you can be given treatment at that time.

Surgery

An operation is done to remove the tumour. Surgery is often used if the cancer is only in one area of the body and has not spread. It may be used to remove lymph nodes if these are also affected by the cancer. It can sometimes be used to remove a cancer that has spread to another area of the body, but this is less common. The type of operation will depend on the area of the body affected by the cancer, and on the size and position of the tumour.

Radiotherapy

This is the use of high energy x-rays to destroy cancer cells, but cause as little harm as possible to normal cells. The radiotherapy is aimed at the affected area of the body and is very carefully planned. It can cause side effects and the most common is tiredness. The side effects will depend on the part of the body that is being treated.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. There are more than 50 different chemotherapy drugs. Some are given as tablets or capsules but most are given by drip (infusion) into a vein. The drugs go into the bloodstream and travel throughout the body to treat the cancer cells wherever they are. Sometimes just one chemotherapy drug is used, but often a combination of two, three or more drugs is given.

Chemotherapy can cause side effects. The side effects will depend on which drug (or combination of drugs) is used. There are now very good ways of preventing or reducing the side effects of chemotherapy.

Hormonal therapy

Hormonal therapies work by altering the levels of particular hormones in the body. Some cancers depend on certain hormones in order to divide and grow. By altering the level of hormones in the body, or blocking the hormones from attaching to the cancer cells the cancer can be controlled.

Biological therapy

Biological therapies use substances that occur naturally in the body to destroy cancer cells. There are several types of biological therapy, including: monoclonal antibodies, cancer growth inhibitors, vaccines and gene therapy.

Monoclonal antibodies are drugs that can 'recognise' and find specific cells in the body. They can be designed to find a particular type of cancer cell, attach itself to them and destroy them. They can also carry a radioactive molecule, which then delivers radiation directly to the cancer cells.

Cancer growth inhibitors interfere with the way cancer cells use 'chemical messengers' to help the cell to develop and divide.

Research is trying to see whether vaccines and gene therapy can be given to treat a cancer that has come back or has spread. Vaccines may also be able to reduce the chance of a cancer coming back, but this type of research is in the very early stages.

Cancerbackup has information on all the cancer treatments mentioned above and also on cancer research trials.

Who gets cancer?

Each year more than a quarter of a million people are diagnosed with cancer in the UK, and 1 in 3 people will develop cancer during their lifetime. But cancer is not common in children or young people - it mainly occurs in the later years of life. Cancers can occur at any age, but the risk of developing cancer increases with age. 64% (64 in 100) of all newly diagnosed cancers occur in people aged 65 years or more. Less than 1% (1 in 100) of cancers are diagnosed in children, aged 0-14 years.

Some cancers are very common and others are very rare. The most recent statistics for the UK (from 2003) show that for men the most common cancer is prostate cancer (23%), followed by lung cancer (16%), large bowel cancer (14%) and bladder cancer (5%).

For women the figures are breast cancer (31%), large bowel cancer (11%), lung cancer (11%) and cancer of the ovary (5%).

Many people with cancer can be cured. Even if a cancer cannot be cured, it can often be controlled with treatment for months or years.

Cancerbackup has information on all the main types of cancer, and on some of the rarer cancers.

Signs and symptoms of cancer

Cancer can often be managed more easily when it is diagnosed in the early stages. Being aware of your body and what is 'normal' for you, and reporting symptoms to your GP, can help to make sure that, if you do have cancer, it is diagnosed as early as possible.

There are some common signs and symptoms that may alert you to the fact that something is new or different. You should contact your doctor if you have any of the following:

Lumps

Knowing how your body normally looks and feels can help you spot any early changes that could be caused by cancer. You should see your GP if you notice a lump anywhere in your body. It can be useful to tell them how long it’s been there and whether it is getting bigger, or causes discomfort. Cancerous lumps are often (but not always) painless.

It can be difficult to tell what a lump is just by feeling it, but if your GP suspects that you might have a cancer, they will refer you to the appropriate specialist for further tests.

It is important to remember that lumps and bumps often occur in the body, and most of these will not be cancer.

Coughing, breathlessness and hoarseness

There are many medical conditions that can cause 'chesty' symptoms like coughing and breathlessness (for example, infections and inflammations), but in some cases these symptoms may be a sign of lung cancer. If you have a cough or feel breathless for more than two weeks you should see your GP. You should also tell your GP if you have any blood in your sputum (phlegm) when you cough.

Laryngitis (inflammation of the larynx) is common and can cause a hoarse voice. In a small number of people, a hoarse voice may be a sign of cancer of the larynx (voice box). If hoarseness continues for longer than two weeks, you should tell your GP.

Changes in bowel habit

Symptoms of bowel cancer may include blood in your stools (bowel motion). The blood would usually be dark but can be bright red in colour. Fresh, bright red blood is usually a sign of piles (haemorrhoids).

You may notice a change in your normal bowel pattern (such as diarrhoea or constipation) for no obvious reason. You might have a feeling of not having emptied your bowel properly after a bowel motion. Some people also notice that they have pain in the abdomen or back passage.

Remember that altered bowel habits aren't always caused by cancer, but can be caused by changes in diet, some medicines, anxiety, and other medical conditions. If any changes last for more than a few weeks it's important to rule out cancer as a possible cause, so you should see your GP.

Bleeding

Any unexplained bleeding is a sign that there is something wrong and should always be checked out by your GP.

As previously mentioned, bleeding from the back passage is most commonly caused by piles, but can sometimes be due to cancer of the bowel or rectum.

Cancer of the womb or cervix can cause women to bleed between periods or after sex. Women who have any vaginal bleeding after they have had their menopause should see their GP. If necessary your GP will refer you to a gynaecologist.

Blood in your urine may be caused by bladder or kidney cancer. It can also be caused by infection. If you notice blood in your urine it is important to see your GP for a check-up.

Coughing up blood in your sputum may be caused by serious chest infections, but can sometimes be a sign of lung cancer.

Vomiting blood can be a sign of stomach cancer, although it can also be due to a stomach ulcer. Therefore, it is important to have this checked out by your GP.

Bruising and nosebleeds are rarely signs of cancer, but can in some cases be caused by leukaemia. However, people with leukaemia often have other troublesome symptoms too.

Moles

Malignant melanoma is a type of skin cancer that often starts with a change in the appearance of normal skin. This can look like an abnormal new mole. Less than a third of melanomas develop in existing moles. It can be difficult to tell the difference between a mole and a melanoma, but any of the following changes should be checked out:

• Asymmetry Moles are usually regular and symmetrical in shape. Melanomas are likely to be irregular or asymmetrical.

• Border Moles usually have a well-defined regular border. Melanomas are more likely to have an irregular border with jagged edges.

• Colour Moles tend to be a single brown. Melanomas often have more than one colour. They may be varying shades of brown mixed with black, red, pink, white or a bluish tint.

• Size Moles are normally no bigger than the blunt end of a pencil (about 6mm (½ inch) across). Melanomas are usually more than 7mm (½ inch) in diameter.

• Itching, crusting or bleeding may also occur in melanomas – these are less common signs but should not be ignored.

It is important to see your GP if you have any unusual marks on the skin that last more than a few weeks, or an existing mole which shows any of the above signs. If necessary they will arrange for you to see a doctor who specialises in skin conditions (a dermatologist) or a surgeon.

Unexplained weight loss

If you have lost a lot of weight over a short period of time (a couple of months), that cannot be explained by changes in your diet, increased exercise or stress, it is important to tell your GP. Other symptoms, such as sickness, pain and fatigue also tend to occur when a person experiences weight loss due to cancer.

What to do if you have worrying symptoms

You usually begin by seeing your GP who will examine you, ask questions about your symptoms, and might ask you to have some tests, such as a blood test or x-ray.

If your GP suspects that you may have cancer, an urgent referral will be made to a specialist. There are guidelines produced by the National Institute for Health and Clinical Excellence (NICE) to help GPs identify when symptoms could be due to cancer or some other condition. An urgent referral usually means that the specialist will see you within two weeks. The specialist can carry out other investigations, such as a biopsy or various scans, to find the cause of your symptoms and plan any treatment necessary.

If your GP thinks your symptoms are not caused by cancer they may still refer you to a specialist for advice, but the referral is likely to be non-urgent and it will take longer for you to be seen.

Remember – in most cases, your symptoms will turn out to be caused by something other than cancer, but they can still be signs of illness and so you won't be wasting your doctor's time by getting them checked out.

References

This section has been complied using information from a number of reliable sources including;

• Clinical Guidelines CG027: Referral for Suspected Cancer. National Institute for Clinical Excellence (NICE). June 2005.
• Souhami and Tobias. Cancer and its Management (5th edition). Blackwell Scientific Publications. Oxford. 2005.
• Souhami et al. Oxford Textbook of Oncology (2nd edition). Oxford University Press. Oxford. 2002.
• DeVita, Vincent T. et al. Cancer: Principles and Practice of Oncology (6th edition). Lippincott. Philadelphia. 2001.

Types of cancer

Carcinomas

The majority of cancers, about 85% (85 in a 100), are carcinomas. They start in the epithelium, which is the covering (or lining) of organs and of the body (the skin). The common forms of breast, lung, prostate and bowel cancer are all carcinomas.

Carcinomas are named after the type of epithelial cell that they started in and the part of the body that is affected. There are four different types of epithelial cells:

• squamous cells - that line different parts of the body, such as the mouth, gullet (oesophagus), and the airways
• adeno cells - form the lining of all the glands in the body and can be found in organs such as the stomach, ovaries, kidneys and prostate
• transitional cells - are only found in the lining of the bladder and parts of the urinary system
• basal cells - that are found in one of the layers of the skin.

A cancer that starts in squamous cells is called a squamous cell carcinoma. A cancer that starts in glandular cells is called an adenocarcinoma. Cancers that start in transitional cells are transitional cell carcinomas, and those that start in basal cells are basal cell carcinomas.

Leukaemias and lymphomas

These occur in the tissues where white blood cells (which fight infection in the body) are formed, i.e. the bone marrow and lymphatic system. Leukaemia and lymphoma are quite rare and make up about 6.5% (6.5 in 100) of all cancers.

Sarcomas

Sarcomas are very rare. They are a group of cancers that form in the connective or supportive tissues of the body such as muscle, bone and fatty tissue. They account for less than 1% (1 in 100) of cancers.

Sarcomas are split into two main types:

• bone sarcomas - that are found in the bones
• soft tissue sarcomas - that develop in the other supportive tissues of the body.

Others forms of cancer

Brain tumours and other very rare forms of cancer make up the remainder of cancers.

What is cancer?

The organs and tissues of the body are made up of tiny building blocks called cells. Cancer is a disease of these cells.

Cells in different parts of the body may look and work differently but most reproduce themselves in the same way. Cells are constantly becoming old and dying, and new cells are produced to replace them. Normally, cells divide in an orderly and controlled manner. If for some reason the process gets out of control, the cells carry on dividing, developing into a lump which is called a tumour.

Tumours can be either benign or malignant. Cancer is the name given to a malignant tumour. Doctors can tell if a tumour is benign or malignant by examining a small sample of cells under a microscope. This is called a biopsy.

In a benign tumour the cells do not spread to other parts of the body and so are not cancerous. However, if they continue to grow at the original site, they may cause a problem by pressing on the surrounding organs.

A malignant tumour consists of cancer cells that have the ability to spread beyond the original area. If the tumour is left untreated, it may spread into and destroy surrounding tissue. Sometimes cells break away from the original (primary) cancer. They may spread to other organs in the body through the bloodstream or lymphatic system.

The lymphatic system is part of the immune system - the body's natural defence against infection and disease. It is a complex system made up of organs, such as bone marrow, the thymus, the spleen, and lymph nodes. The lymph nodes (or glands) throughout the body are connected by a network of tiny lymphatic ducts.

When the cancer cells reach a new area they may go on dividing and form a new tumour. This is known as a secondary cancer or metastasis.

It is important to realise that cancer is not a single disease with a single type of treatment. There are more than 200 different kinds of cancer, each with its own name and treatment.

Bart's Mesothelioma Research

Bart's Mesothelioma Research

Bart’s Mesothelioma Research is a group of doctors, nurses and laboratory researchers aiming to improve the treatment and increase our understanding of mesothelioma and lung cancer. Mesothelioma is the main type of cancer caused by asbestos poisoning. Mesothelioma and other asbestos-related illnesses such as lung cancer and pleural plaques are increasing in incidence even though asbestos was little used after 1980. The problem is that there is a delay of between 30 and 50 years from the exposure to asbestos dust and the development of one of the diseases.

Britain is currently facing an epidemic of asbestos-related illness. Unfortunately there is very little research going on into mesothelioma in the UK. Bart’s Mesothelioma Research is aiming to raise the profile of this neglected group of diseases by offering our patients the best possible treatment and by conducting first-rate clinical and laboratory research.

At Bart’s we have one of the largest outpatient clinics in the UK for patients with mesothelioma. Typically our doctors see two or three new patients weekly. We also see a large number of patients who have completed treatment and are being followed up. We take a very positive view of treatment for mesothelioma and our patients are treated as individuals with treatment tailored accordingly. Treatments that we use include chemotherapy, radiotherapy and surgery. All patients are assessed in detail for symptoms by our team which also includes cancer specialist nurses.

Mesothelioma is cancer of the lung pleura or the abdominal peritoneum. The cancer arises in the membranous coverings of the lungs or bowels. Eventually the membrane becomes thickened and rubbery. Problems with breathlessness, chest pain and cough occur in many patients, though modern treatments can be very effective at abolishing these symptoms. Other symptoms that we see include weight loss, low energy levels and night-time sweating. Surgery to remove the cancer can be done in a few patients but most patients are treated with chemotherapy, radiotherapy and supportive treatments such as painkillers and appetite-boosting tablets. No patient is identical to another and, as discussed above, all patients are treated as individuals.

Research is central to our approach. It is imperative that we learn more about mesothelioma so that we can help current patients as well as patients of the future. What we learn about mesothelioma will help us understand other types of cancer such as breast, bowel and conventional lung cancer. Research at Bart’s takes two forms:

Clinical Trials

We have a programme of clinical trials which was initiated in the mid 1990s. Treatments pioneered at Bart’s have become accepted around the world. We cannot afford to stop where we are however, and much more progress is needed. We always have clinical trials available for patients. We also offer the standard best available treatments for patients who prefer not to be included in research trials. Some patients prefer a ‘watch-and-wait’ approach and we are supportive of this. Mesothelioma cancers tend to vary in their speed of growth and a period of observation is often very appropriate.

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