UNDERSTANDING CANCER

The word ‘cancer’ is an umbrella term referring to about 200 known diseases
affecting humans, of which the name is so given based on the location/part of the
body where it starts – eg. breast cancer - breast, stomach cancer - stomach
etc.
All these diseases have two common characteristics:

1. an uncontrolled growth of cells and

2. the ability to invade and damage normal tissues either locally or at a
distant site of the body.

To understand cancer, it's helpful to know or understand to a certain degree how

a normal cell becomes a cancerous cell, how it develops and spreads through
your body.

2.1 LIFE CYCLE OF CELL

The beginning of life

We all begin life as a single cell (a fertilized egg) in the womb. This single cell
multiplies and forms communities of cells (trillions of them), which specialize into
many different cell types in the body during early growth depending on which
function they perform eg. brain cell, blood cell, etc.
All our bodily functions are carried out by cells and these cells communicate with
each other, carry out self- repair and self- regulation. Both normal and
cancerous cells are produced and destroyed all the time.
Our body produces millions of new cells every minute and these new cells
develop from pre-existing cells through a process of cell division called ‘mitosis’
and between 500 and 700 billion cells die each day due to ‘apoptosis’
(programmed cell death).
During the early years of a person’s life, normal cells divide faster to allow the
person to grow. After the person becomes an adult, most cells divide only to
replace worn-out or dying cells or to repair injuries.
Do note that along with the normal cells, ‘abnormal’ cells are sometimes
produced in the body and this is no cause for alarm.

2.2 DIFFERENCE BETWEEN ‘NORMAL’ AND ‘ABNORMAL’

CELLS

Simplistically, the main difference is that normal cells are programmed to live and
after a certain time (ranges from days to months) will undergo ‘apoptosis’ -
a programmed cell death which follows a controlled, predictable routine. When
this occurs, the old cell will be replaced with a new one.
However, in ‘abnormal’ cells, due to a series of changes (mutations) in the cell
they are damaged and cannot be destroyed through this normal
process. These disturbances in its cellular functioning may cause it to become
cancerous – especially if the terrain is conducive.
A few ‘abnormal’ cells within the body do not cause immediate damage for they
need time and resources to build into a dangerous mass and this can take
anywhere between 1 – 40 years. In addition, when our immune system is
healthy, it is able to detect and destroy these aberrant (abnormal) cells just as it
does with invading viruses and bacteria, thus preventing the cancer cells from
overwhelming the body.
However, if our immune system is weak, these cancer cells can slip through the
defense system and begin to multiply uncontrollably and induce formation of new
blood vessels to supply the required nutrients to the cancerous mass. Initially
they grow where they first occur, but small clumps can break off and travel in the
blood or lymph system to other parts of the body and grow there. When this
happens, it is called ‘metastasis’or circulating tumor cells.

2.3 THE ONSET OF CANCER

Cancer is first and foremost a disease of the cell; the smallest and the most
fundamental component of the human body. The onset of cancer is a gradual
phenomenon, evolving quietly over a period of time before symptoms appear.
Broadly, we can divide the development of cancer in 4 steps: initiation, promotion,
progression and metastasis (spreading).
Stage 1 - Initiation
In the initiation stage, some kind of a change is happening in a cell that begins
the carcinogenic or mutation process. Although there are many kinds of cancer,
all cancers begin with ‘abnormal cells’ that grow out of control. How does ‘normal
cell’ become abnormal? It becomes ‘abnormal’ because of the damage to its DNA*
or the adaptation changes within the cell to the environmental influences (survival
mechanisms).
*DNA (deoxyribonucleic acid) is the genetic ‘instruction manual or the blue print’
found in all the cells.
What causes ‘damage DNA’ or the adaptive changes?
Our cell is under constant bombardment and damage can occur. The damage to
the cell can occur in the following ways:
randomly, caused by mistakes in the normal DNA replication

 inherited genetically
 exposure and contact with viruses and carcinogenic substances such as free
radicals, ionizing radiation and chemicals in smoke or things we eat.

In a normal cell, when the DNA/ cell is damaged the cell either repairs itself or goes
into suicide mode. Abnormal cells are also destroyed by our immune
system. However, when the ‘abnormal’ cells are not repaired and they do not die,
they develop mechanisms to evade the ‘immune system’. They will live on,
multiplying and making an army of ‘abnormal cells’. These abnormal cells may not
be cancerous at this stage – but they could potentially be, given the chance.
The ‘abnormal cells’ remain vulnerable; only some will succeed in progressing
further and to achieve these, there must be ‘factors or conditions’ that promote
proliferation (or growth). In most cases, the damaged cells may form a tumor (see
insert on page 14 for more on tumor). Over time, the tumors can replace normal
tissue and form lumps or swellings. Some cancers, like leukemia, rarely form
tumors. Instead, they involve the blood and blood-forming organs and circulate
through other tissues where they grow.

Stage 2 - Promotion
In this next section we will briefly review risk factors that have been well
documented over the years as the factors that may trigger the onset of cell mutation,
aberrant behavior and promote its growth.

FACTORS THAT CAN TRIGGER AND PROMOTE CANCER

We all have a risk of developing cancer and Table 1—The percentage
some have more risk than contribution of the various factors
others. Understanding the factors that promote to cancer is as shown below:
the development of cancer is crucial to enable us
to acquire an increased understanding of the
cell’s behavior as well as to formulate strategies
for treating it.
Almost everyone knows that smoking can cause
cancer, but very few people realize that daily
activities such as eating and lack of physical
activities can also result in cancer.
Intriguing scientific research has shown that our
risk in developing cancer actually depends on a
combination of genes, environment and also
*The lower percentage has been
lifestyle. Despite popular belief, only about 5%
taken, except alcohol the original
of cancer incidence is attributable to genetic
data was 4-6%
defects while the remaining 90–95% actually
have their roots in the environment and Source: National Center for
lifestyle. While a cellular mutation may be the Biotechnology Information - Cancer
beginning of the cancer process, the underlying is a Preventable Disease that
mechanisms that initiate the cascade of Requires Major Lifestyle Changes
molecular events that lead to the growth and 2008 July 15 – read more at
aggressiveness of cancer is inflammation*,
caused by the interaction of our genes within http://www.ncbi.nlm.nih.gov/pmc/ar
their environment. ticles/PMC2515569/

Various factors which increase inflammation in

the body include carcinogens (cancer causing agents) from tobacco, alcohol, diet
(excess or lack of), obesity, infections, radiation (both ionizing and non-ionizing), stress,
emotion, lack of physical activity, substance exposure at work, insulin like growth
hormone, environmental pollutants and other factors. Insulin like growth hormones can
also play a key role in ‘damaged cells’ proliferation.
Regular or prolonged exposure to the above ‘factors’ enables the damaged cells to gain
characteristics which render the cells more malignant.
* Inflammation is the body's response to any tissue damage, be it caused by injury,
infection, exposure to toxins or other types of trauma. The body's inflammatory
response (swellings, redness, tenderness) triggers immune responses that result in
repair of the damaged tissue, and begin the healing process at the site of the injured
tissue.
 GENETICALLY OR EPIGENETICALLY INFLUENCED, WHAT IS
YOUR TAKE?
Let’s remind ourselves that historically cancer was a rare disease. It is only in the
early part of the twentieth century that cancer has increased dramatically, especially
in industrialized nations. For example, cancer occurrence in America in the early
1900s was rare and affected only 3% of its population, yet right now almost one in
three Americans will be diagnosed with cancer in their lifetime1. In Malaysia, it is
estimated that one in four Malaysians (1:4) will develop cancer by the age of
75 2. A disease once associated with the affluent nation is now increasingly common
even in developing countries like Malaysia.
Your view and belief on the role of genetics in the evolution of cancer is crucial
because it affects your perception and subsequently how you prevent/ treat cancer.

GENETICALLY ORIENTED?

Those in this school of thought will likely be looking to the human genome for
solutions to most chronic illnesses, including the diagnosis, prevention, and treatment
of cancer. In a recent high profile case, the famous American actress Angelina Jolie
underwent a double mastectomy after she was found to be carrying the ‘faulty’
BRCA1 gene, giving her an estimated 87 per cent chance of developing breast
cancer and 50 per cent risk of developing ovarian cancer. Her belief in genetic
science caused her to remove her pair of normal breasts to reduce the risk of
cancer. A believe that genes are the cause of cancer renders us powerless against
the disease and the way forward is to target the malignant cell with chemo and
radiation, along with surgery to remove the cancerous cell or tissues that may
potentially become cancerous.
On the other hand, many reputed studies have revealed that 90-95% of cancer cases
are actually linked to lifestyle and environmental factors (epigenetics). These studies
have indicated the relative significance of certain lifestyle factors such as smoking,
poor diet, obesity, drinking and etc. increases the risk not only of cancer but also of
a range of other serious chronic conditions such as cardiovascular diseases and
diabetes. When we accept that the vast majority of cancers are not caused by genetic
defects it means that in most cases we have the power to modify or eliminate most
of the factors that lead to it.
For example, the one thing we know for sure is that obesity increases the risk of a
number of different types of cancer. For example, with hormonally driven cancers
such as breast cancer, obese patients have a worse prognosis. Therefore, to reduce
the risk of developing breast cancer (even for women with BRCA1 and BRCA2 genes)
is to control their weight, improve their nutritional status and to exercise regularly.
Believing that you are in control of the situations that affect your body will provide
you with far more opportunities to prevent and treat cancer.

GENES HAVE VERY LITTLE IMPACT ON LIFE OUTCOMES3

 After sequencing his own genome, pioneer genomic researcher Craig Venter
remarked at a leadership for the twenty-first century conference that “Human biology
is actually far more complicated than we imagine. Everybody talks about the genes
that they received from their mother and father, for this trait or the other. But in reality,
those genes have very little impact on life outcomes. Our biology is way too
complicated for that and deals with hundreds of thousands of independent factors.
Genes are absolutely not our fate. They can give us useful information about the
increased risk of a disease, but in most cases they will not determine the actual cause
of the disease, or the actual incidence of somebody getting it. Most biology will come
from the complex interaction of all the proteins and cells working with environmental
factors, not driven directly by the genetic code”

Stage 3 - Progression
At the progression stage the damaged cells override the normal signaling system
that regulates their growth. They continue to reproduce rapidly, form new vessels
by angiogenesis and refuse to die.

Stage 4 - Metastasis
Metastasis is the spread of cancer to the other locations in the body and is very
common in the later stages of cancer. It can occur via the blood or the lymphatic
system or both. The cancer that a patient begins with, becomes very different in
the later stages; more mutated and difficult to treat.

2.4 CLASSIFICATIONS OF CANCER

Cancer classification is generally made according to the site of origin of the
malignant cells. Here are some common examples of site of origin
classification. ( not an exhaustive list )
Carcinoma : Cancers arise in the epithelium (the layers of cells covering
the surface of the body and the lining of internal organs and various glands)
Sarcomas : Cancers originating from the supporting/ connective tissues
of the body, such as bone, muscle, cartilage, fat and blood vessels.
Leukemias : Cancers involving blood and blood-forming organs such as
bone marrow, lymphatic system and spleen
Lymphomas : Cancers originating from the lymphatic glands and systems
Gliomas : Cancers of the nerve tissue
Melanomas : Cancer of the skin
Myeloma : Originates in bone marrow
Blastoma : Originates in embryonic tissue of organs
Adenocarcinoma : Originates in glandular tissue
Leiomyosarcoma : Originates in smooth muscle
Neurosarcoma : Originates in the nerve cell
Liposarcoma : Originates from fat cells

TUMOR OR CANCER?

2.5 TOOLS FOR FINDING OR DIAGNOSING CANCER

Some people panic upon finding out that they have lumps but some fail to get proper
treatment because they dismiss a simple lump as not cancerous.
Are all lumps or swellings cancerous? Not necessarily.
A tumor is basically a swelling, a mass, lump or lesion formed in your body by an
abnormal growth of cells. It can be:
¨ benign (non-cancerous)
¨ pre-malignant (pre-cancerous or a growth that is probably harmless at the moment
but does have a significantly increased risk of cancer.
¨ malignant (cancerous).
Example of benign growth would be ‘lipoma’, the fatty encapsulated lumps beneath
the skin of the arms, neck or back, unsightly but do no harm. For women, lumps may
also be noted in the breast tissues especially before their menstrual cycle, these
usually disappear after a few days.
Although benign tumors are mostly harmless, some may have negative health
effects, such as pushing against vital organs or blood vessels or overproduction of
certain hormones. Due to this, benign tumors may still need to be removed via
surgery. Removing a benign tumor is relatively easy through surgery, and that’s it -
the condition does not recur.
The way to check if a tumor is cancerous is through a BIOPSY, a procedure where a
small sample of tissue from the mass is taken and a series of tests performed to
determine if the tumor is cancerous.

Tools for finding or diagnosing cancer

¨ Ultrasound — the use of reflected high-frequency sound waves to examine tissues
of the body;
¨ Biopsy — removal of a small piece of tissue, which is looked at under a
microscope;
¨ X-ray — producing an image by passing x-rays through the body;
¨ Computed tomography (CT) — the use of x-rays to produce a cross-sectional
picture of body parts; and
 ¨ Magnetic resonance imaging (MRI) — the use of magnetic fields and radio waves
to show changes in soft tissues without the use of x-ray
Mammogram, Ultrasound, X-ray, CT, and MRI are all painless and noninvasive;
however, having too many CTs or x-rays can increase your risk of developing cancer
because they expose you to radiation. Other tools for finding and diagnosing cancer
or abnormal cells that may become cancer include Pap tests, which look for
abnormal cervical cells; HPV DNA tests, which look for DNA from cancer-causing
HPV types in cervical cells; fecal occult blood tests (FOBT), which check for blood in
the stool; sigmoidoscopy,which examines the lower colon; and colonoscopy, which
examines the entire colon. Some people choose to do self-exams, such as feeling
around their breasts or testicles for new lumps or looking over their skin. If you notice
anything unusual, consult your doctor.
In summary, when you have cancer, irrespective of where it shows up; the cause is
the same – malfunctioned cells or cells that refused to die. While some of us may be
unfortunate enough to carry the ‘cancer gene’, it is important to know that this
incidence is relatively small ie. 5 - 10% and that these genes may not be ‘activated’
in an environment which is not favorable to their growth. By and large it is the
‘epigenetic’ factors that are hugely responsible for the increase in the cancer
incidences.
What if I have a gene associated with cancer? Firstly, it does NOT mean that you
will definitely get cancer. It simply means that it is a risk factor. It is similar to the
other non-genetic risk factors like smoking, toxin exposure or diet—the strategy is to
make preventive lifestyle and behavioral changes that discourage the expression
and/ or the growth of the cancer cells.
Sources of carcinogens ( and therefore damage to cells ) turn up in things that
we least expect; detoxification is therefore imperative to maintain optimal
health.

Sources:
1. American Institute of Cancer Research.

2. National Cancer Society Malaysia).

3. 'Genes have very little impact on life outcomes' - Dr. J. Craig Venter
Pioneering Genomic Researcher