Symptoms and cancer

DEFINITION: Symptoms are outward signs such as swellings, lumps, pain, shortness of breath, rashes, and many other unusual conditions a person may experience due to an underlying disease or other pathology. Some symptoms may be warning signs for undiagnosed, site-specific cancers. Their early or timely recognition is critical to the treatment and relief of symptoms. Because of rapid scientific advances, it is increasingly important to comprehensively manage symptoms as a central component of cancer treatment plans. Quality of life and maintenance through aggressive symptom management efforts are as important. The length of survival is of considerable interest as science and technology can keep individuals alive for lengthening periods, but often with marginal quality of life. It is essential to differentiate discrete symptoms through refined and evolving assessment strategies so treatments that promote quality of life may be symptom-specific.

Symptoms as warning signs: To function as warning signs of undiagnosed, site-specific cancers, well-documented, established symptoms, and symptom clusters or profiles must be well publicized, using methods that are understandable and palatable to an increasingly diverse population. Public information should make it easy for people to receive timely medical attention, consisting of a diagnostic workup, definitive medical or surgical recommendations, and timely intervention. Public education regarding the signs and symptoms of cancer is essential to promote early diagnosis, improve cure and survival rates, and minimize disability and healthcare costs. Many online resources deliver information regarding early symptoms and warning signs of cancer. This information can be accessed in a private, confidential manner and may facilitate action among individuals who would otherwise be hesitant to seek medical advice promptly. Common psychological issues such as depression, fear, and anxiety sometimes prevent people from seeking medical attention even when aware of symptoms.

Cancer symptoms: The following symptoms may be early warning signs for site-specific cancers and, if experienced, are reason to seek medical attention for a definitive diagnosis:

• Bladder cancer: Blood in the urine (hematuria), pain or burning upon urination, frequent urination, or cloudy urine, lower back pain on one side of the body, abdominal pain
• Bone cancer: Pain in the bone or swelling around the affected site, fractures in bones, weakness, fatigue, weight loss, repeated infections, nausea, vomiting, constipation, problems with urination, weakness or numbness in the legs, bumps and bruises that persist
• Brain cancer: Dizziness; drowsiness; abnormal eye movements or changes in vision; weakness or loss of feeling in arms or legs or difficulties in walking; fits or convulsions; changes in personality, memory, or speech; headaches that tend to be worse in the morning and ease during the day, which may be accompanied by nausea or vomiting
• Breast cancer: A lump or thickening of the breast, discharge from the nipple, change in the skin of the breast, a feeling of heat, enlarged under the arm
• Colorectal cancer: Rectal bleeding (red blood in stools or black stools), abdominal cramps, constipation alternating with diarrhea, weight loss, loss of appetite, weakness, pallid complexion
• Kidney cancer: Blood in urine; dull ache or pain in the back or side; lump in kidney area, sometimes accompanied by high blood pressure or abnormality in red blood cell count
• Leukemia: Weakness; paleness; fever and flu-like symptoms; bruising and prolonged bleeding; enlarged lymph nodes, spleen, or liver; pain in bones and joints; frequent infections; weight loss; night sweats
• Lung cancer: Wheezing; persistent cough for months; blood-streaked sputum; persistent ache in chest; congestion in lungs; enlarged lymph nodes in the neck
• Melanoma: Change in mole or other bump on the skin, including bleeding or change in size, shape, color, or texture
• Non-Hodgkin lymphoma: Painless swelling in the lymph nodes in the neck, underarm, or groin; persistent fever; feeling of fatigue; unexplained weight loss; itchy skin and rashes; small lumps in skin; bone pain; swelling in the abdomen; liver or spleen enlargement
• Oral cancer: A lump in the mouth; ulceration of the lip, tongue or inside of the mouth that does not heal within a couple of weeks; dentures that no longer fit well; oral pain or bleeding; foul breath; loose teeth; changes in speech
• Ovarian cancer: Abdominal swelling; in rare cases, abnormal vaginal bleeding; digestive discomfort
• Pancreatic cancer: Upper abdominal pain, unexplained weight loss, pain near the center of the back, intolerance of fatty foods, yellowing of the skin, abdominal masses, enlargement of liver and spleen
• Prostate cancer: Urination difficulties due to blockage of the urethra; bladder retains urine, creating frequent feelings of urgency to urinate, especially at night; bladder not emptying completely; burning or painful urination; bloody urine; tenderness over the bladder; dull ache in the pelvis or back
• Stomach cancer: Indigestion or heartburn, discomfort or pain in the abdomen, nausea and vomiting, diarrhea or constipation, bloating after meals, appetite loss, weakness or fatigue, vomiting blood, or blood in the stool
• Uterine cancer: Abnormal vaginal bleeding, a watery bloody discharge in postmenopausal women, painful urination, pain during intercourse, pain in the pelvic area

Symptoms after cancer diagnosis: Identification and treatment of distressing symptoms that occur as a result of cancer or its treatment are paramount so that quality of life and comfort are optimized for the cancer patient. As people live longer following cancer diagnosis, symptom management is an increasingly important aspect of treatment. However, many factors interfere with prompt recognition and treatment of these symptoms.

The period between diagnosis and beginning treatment is marked by medical evaluation, developing relationships with medical personnel, and the need to integrate a barrage of frightening and confusing information. Patients and families experience heightened responsibility, concern, and isolation. They are particularly anxious and fearful when receiving initial information regarding diagnosis and treatment. Consequently, professionals should carefully repeat information over several sessions to inquire about patients’ and families’ understanding of facts and options. Early assessment by clinicians can help identify individuals at risk for medical or psychological adjustment problems, particularly those in the greatest need of ongoing psychosocial support and symptom management. Patients with ongoing involvement with medical personnel and repeatedly receiving accurate and consistent information about what to expect have less uncertainty and are less likely to develop maladaptive coping strategies.

Although many studies document the devastating emotional impact of a cancer diagnosis, many individuals cope effectively, experience minimal distress, and have a high quality of life throughout most aspects of the cancer experience. Effective coping strategies, such as taking action and finding favorable elements of the situation, have been associated with positive treatment experiences. Contrary to the beliefs of many clinicians, denial has been found to assist patients to cope effectively unless sustained and used to the point that it interferes with obtaining recommended treatment.

Healthcare providers play a vital role in monitoring physical comfort and psychosocial adjustment and managing problems as they arise. As cancer progresses, patients often report an upsetting scenario that includes frequent pain, disability, increased dependence on others, and diminished functional ability, which usually results in psychological symptoms. Investigators studying quality of life in cancer patients have demonstrated a clear relationship between discomfort and a patient’s perception of quality of life. As uncomfortable symptoms increase, the perceived quality of life diminishes. Therefore, an essential goal in the psychosocial treatment of patients with advanced cancer focuses on symptom control.

Patients who are diagnosed with late-stage disease or have aggressive illnesses with no hope for cure are often the most vulnerable to psychological distress, particularly anxiety, depression, and family problems, and physical discomfort, including pain, fatigue, shortness of breath, and confusion. When physicians cannot offer patients hope for a cure, helping them maintain comfort and control promotes adaptation and improved quality of life. One of the highest levels of psychological distress, with an increase in depression, anxiety, and thoughts of suicide, occurs in patients who have a recurrence of their cancer, which is often associated with an adverse outcome or advanced disease.

The patient’s culture significantly influences the perception of distressing symptoms such as pain. Some researchers have found that the best predictors of pain intensity are ethnic affiliation and locus of control style. For example, an individual’s stoic attitude, which minimizes or negates discomfort, may be related to a cultural value learned and reinforced through years of family experiences. Similarly, an individual’s highly emotional response to routine events may become exaggerated during the terminal phase of illness and not necessarily signal maladjustment but rather a cultural norm.

Knowledge of an individual’s response to illness and symptom expression is enhanced through awareness of the person’s family traditions and culture. Understanding a patient’s cultural, religious, ethnic, and socioeconomic underpinnings is critical to understanding that person’s beliefs, attitudes, practices, and behaviors related to illness and death. Cultural patterns play a significant role in determining how patients cope with terminal stages of cancer when symptoms such as delirium, depression, thoughts of suicide, and severe anxiety are common. When severe, these symptoms require aggressive treatment using up-to-date pharmacological and psychotherapeutic treatment strategies.

Despite the seemingly overwhelming nature of physical discomfort and psychosocial stress associated with cancer, most patients can be relatively symptom-free and cope effectively throughout the experience. Differentiating psychiatric complications from adaptive coping and differentiating normal from pathological emotional distress can be challenging. For example, anxiety and depression are normal responses to traumatic events such as a cancer diagnosis or progression of a life-threatening illness. They are typical and expected at transitions throughout the cancer experience. Clinicians can distinguish between patients who need aggressive psychiatric intervention and those needing routine support and information by looking at factors such as whether the patient has a prior psychiatric history, including hospitalization, and has used or is using psychopharmacologic treatments and the intensity and duration of symptoms and how much they diminish functioning. These factors can also help clinicians determine whether the patient has a lasting psychiatric disorder or transient psychological symptoms that will dissipate without specific treatment.

Psychological symptoms may also emerge when physical discomfort escalates or is not well controlled and diminishes following treatment of physical pain. Health professionals, family, and friends can monitor the patient’s symptoms to determine what is normal and what indicates the need for intervention. They can also observe whether the patient’s usual coping patterns remain effective. When psychological stress worsens over time and does not respond favorably to the usual supports, aggressive psychiatric assessment and management should be instituted.

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