• 11/18/2004
  • Amy Dockser Marcus
  • Wall Street Journal Online

All too often, the pain of a cancer diagnosis is compounded by the realization that the disease could have been caught sooner if only the early symptoms had been recognized.

Indeed, for all the enormous strides in cancer-screening technologies, some very basic red flags — back pain, constipation, fatigue, even a hoarse voice — are often overlooked because they resemble the symptoms of benign diseases. Patients are unlikely to call a doctor right away, and when they do, doctors may spend months looking for other causes before suspecting cancer.

But there is a growing recognition in the cancer community that identifying physical symptoms is vital. Existing screens still miss many tumors, and no effective screens even exist for some particularly lethal cancers, such as pancreatic and ovarian.

As a result, a concerted effort is under way to educate patients, doctors and medical students to identify early symptoms of cancer. Diagnostic tools are also in the works that can help physicians put the pieces together and see when a particular constellation of symptoms may indicate cancer.

A challenge in this, of course, is how to encourage patients and doctors to recognize symptoms without creating panic over every itch and twinge. Cramping and fatigue can be signs of colon cancer, but they could also signify less threatening digestive problems. Coughing and chest pain are early symptoms of lung cancer, but also of a bad cold. Pain in the abdomen or back can signal pancreatic cancer, but how many adults over 40 haven’t experienced both?

Cancer experts emphasize that rather than reacting to every little symptom, the key is to consider the combination of symptoms, the severity, and when they started. Intestinal problems in someone who has been diagnosed with diabetes during the past two years could be a red flag for pancreatic cancer. Vaginal bleeding that occurs after age 50 can be a sign of cancer of the cervix or the endometrium, the lining of the uterus.

Ayala Miron was diagnosed in April 2000 with advanced ovarian cancer at the age of 43. In the two years prior to her diagnosis, she had complained to her doctor of a variety of symptoms.
She felt faint chest pains when she took deep breaths so she got sent for a chest X-ray, which was normal. She complained about several episodes of sharp pain and was told to take Advil. She felt fatigue and bloating. Eventually severe abdominal pain landed her in the emergency room, where doctors initially misdiagnosesd it as inflammation of the digestive tract. It was only after her husband insisted she get a CT scan that advanced ovarian cancer was diagnosed.

“I learned later that all my symptoms are common in ovarian cancer,” she says. In fact, she had other signs as well, such as spotting between periods, longer-than-usual periods, frequent urination and lower back pain, that she didn’t even mention to a doctor. No one, including herself, saw her symptoms as connected. And as a result, she says she underwent much more aggressive treatment than would otherwise have been needed.

National Cancer Institute figures illustrate how often cancers are caught late. In 1995-2000, only 8% of patients with pancreatic cancer were diagnosed when the cancer was confined to the organ. Only 39% of colorectal cancers were caught at the earliest stage, 19% of ovarian cancer, 34% of oral cancer and 16% of lung cancer.

Education Efforts

A number of initiatives to identify early symptoms — and help people distinguish them from everyday aches and pains — are under way. The Oral Cancer Foundation has been working with the American Dental Association to encourage dentists to check for potentially cancerous lesions inside people’s mouths as a regular part of routine dental care. And patient advocacy groups from the Sarcoma National Foundation to the Pancreatic Cancer National Action Network are encouraging patients to be more aware of the symptoms of cancer.

The Ovarian Cancer National Alliance is sponsoring a program that brings ovarian-cancer survivors to talk with third-year medical students and to draw attention to early symptoms, which include bloating or fullness in the abdomen, unusual lower-back pain and constipation or diarrhea. Barbara Goff, a professor of obstetrics and gynecology at the University of Washington, is developing what she calls an Ovarian Cancer Symptom index, a tool that will enable primary-care physicians to chart patients’ symptoms and then refer those who get a certain score on the index for further testing. The index will be tested in the next year, and Dr. Goff hopes it could serve as a model for other cancers, particularly ones where there is currently no screening test.

“Internists who say that women complain all the time about benign symptoms that are similar to the symptoms of cancer are right,” says Dr. Goff. But in an introduction she wrote to a book about cancer survivors, “Ovarian Cancer Journeys, Survivors Share Their Stories to Help Others,” she said her research demonstrated that women with cancer were more likely to have symptoms that were “more severe, more frequent and of more recent onset,” than women with the same symptoms in the general population.

Patient Awareness

Brian Hill, founder and executive director of the Oral Cancer Foundation, has pressed to make patients more aware of the symptoms of oral cancer and to urge dentists who spot visible lesions to refer patients for further tests.

He emphasizes that patients with sores or lesions that appear benign but don’t heal or resolve themselves within 14 days should be sent for further testing.

Mr. Hill wasn’t diagnosed with oral cancer until he felt a hard lump on his neck and went to see an ear, nose and throat specialist. That doctor looked in his mouth and saw a red patch on his tonsil the size of a quarter. Thinking it was an infection, he prescribed antibiotics. But when the lump didn’t change after a week on the medicine, Mr. Hill was referred for a biopsy, which confirmed it was advanced oral cancer.

Lost Time

Mr. Hill says the doctor estimated the lesion had been growing for maybe 18 months. In that period, he had had a variety of dental procedures done, but no one said anything, and he was unaware of it himself.

If the cancer had been caught earlier before it spread to his neck, treatment might have been simpler. As it turned out, he needed radical surgery to remove a portion of his neck.

“So many people were looking in my mouth,” says Mr. Hill. “But no one thought it could be cancer.”

Reading the Signs

Below are some common signs associated with cancer. Many of these symptoms are the same as those for benign conditions, and simply having these symptoms doesn’t mean you have cancer. But if you are not feeling well or notice that you have some of these symptoms, it is important to tell your doctor.

Breast Cancer
A lump or swelling in the breast
Nipple pain or the nipple turning inward
Redness, scaliness of the nipple or breast skin
Discharge from the nipple other than breast milk

Lung Cancer
A cough that does not go away
Chest pain
Hoarseness
Bloody or rust-colored spit or phlegm

Ovarian Cancer
Bloating or fullness in the abdomen
Unusual abdominal or lower back pain
Unusual lack of energy
Constipation or diarrhea

Prostate Cancer
Blood in the urine
Impotence
Pain in the hips, spine, ribs
Loss of bladder or bowel control

Colorectal Cancer
Change in bowel habits, such as diarrhea or constipation, that lasts for more than a few days
Rectal bleeding or blood in the stool
Cramping or steady pain in the abdominal area
Weakness or fatigue

Oral Cancer
Sore or pain in the mouth that does not go away
Difficulty chewing or swallowing
Lump or mass in the neck
Persistent white or red patch on the gums, tongue, tonsils or lining of the mouth

Pancreatic Cancer
Jaundice
Diabetes mellitus (high blood sugar)
Pain in the abdomen or back
Digestive problems