Cancer: clinical features and management

Cancer is common and will be the cause of death of about 20% of the population of developed countries. Every clinician should be aware of the many ways in which it presents. Delay in diagnosis may diminish the chances of successful treatment and always creates anxiety for the patient. Expert advice, immediate investigation, and definitive biopsy diagnosis should be obtained speedily.

Clinical features

Symptoms—common symptoms include (1) pain—a presenting feature of 30% of cases of cancer, with sites and distribution that may be characteristic of tumours in certain locations and indicators of a possible underlying malignancy; more likely to occur with rapidly growing tumours; when due to bone involvement is typically worse at night-time; (2) swelling—due to tumour mass; (3) weight loss—an invariable accompaniment of advanced cancer and also a frequent presenting symptom; may be due to direct interference with digestive function, production of factors leading to weight loss and anorexia by the tumour, and possible alteration in protein and energy metabolism.

Other clinical manifestations—these include (1) fever—particularly in lymphomas, renal carcinoma, and any cancer metastatic to the liver; (2) anaemia—usually normochromic; (3) hypercalcaemia—usually due to widespread skeletal metastases, but sometimes paraneoplastic and due to action of parathyroid hormone-related protein (PTH-rP); and (4) paraneoplastic manifestations—these may be endocrine, neurological, dermatological, musculoskeletal, or haematological; frequently present as puzzling medical problems at a time when the primary tumour may not be clinically apparent.

Emergency presentations—many presentations and complications of cancer are medical emergencies that require immediate treatment. These include spinal cord compression, raised intracranial pressure, pathological fractures, pleural and pericardial effusion, ascites, and metabolic disturbances such as hypercalcaemia.

General aspects of investigation and management

The diagnosis and immediate management of suspected cancer requires (1) a high index of clinical suspicion—cancer should be suspected with any unexplained illness, especially in older people; (2) obtaining a tissue diagnosis without undue delay—radiological imaging will often accelerate diagnosis but cannot provide a tissue diagnosis; every attempt should be made to make a histological or cytological diagnosis expeditiously; (3) initiation of treatment without undue delay—patients should start a planned programme of treatment within days, not weeks, of diagnosis.

The multidisciplinary approach—the management of a patient with cancer increasingly involves specialists in different disciplines who, at the outset, decide on the nature and sequence of treatment. These decisions are based on the stage of the tumour (local extent, presence of absence of lymph node spread, presence of absence of distant metastases) and other clinical and pathological determinants of prognosis, and on the likelihood of benefit from surgery, radiotherapy and chemotherapy.

Psychological and pastoral care, and management of pain—these are essential and rewarding aspects of cancer medicine. The attitudes of the medical team and the efficiency, openness, and responsiveness of the organization of care are of great importance in helping the patient cope with the stress of the diagnosis and its treatment.

Long-term consequences of cancer and its treatment—these are now occurring increasingly frequently as cure rates rise. They affect every aspect of general internal medicine and physicians in all specialties need to be aware of the nature of the problems that may occur, which include reduction in fertility, cognitive impairment, musculoskeletal problems, metabolic problems, and second cancers.