1. Cervical Dysplasia
   
2. Pre-cancer of the Breast?
   
3. Oral Pre-cancers
   
4. Actinic Keratosis
   
5. Barrett's Esophagus
   

Cervical Dysplasia

Pre-cancer of the cervix is an abnormal growth of cells on the cervix (the mouth of the womb). If not treated, some of these cell growths may become cancer. Because of improved screening tests, cancer of the cervix is becoming less common in the United States.

There are no signs or symptoms related to early cervical cancer, so a pelvic exam of the female sex organs is needed to test your cervix. During this exam, cells are gently scraped from the cervix and later examined under a microscope. This is the basic Pap smear. Although not perfect, it is a good screening tool for cancer and precancer of the cervix. A Pap smear is suggested for all sexually active women or by age 18. It should be repeated every one to three years based upon individual risk.

Women at greater risk for pre-cancers include those who:

• had sex before the age of 18
• have more than two sex partners
• smoke cigarettes
• do not use barrier birth control (such as condoms or a diaphragm)
• have a history of herpes, genital warts, or HIV or
• have had limited access to healthcare

Most low grade pre-cancer will disappear without treatment. Some will remain and slowly grow into cancer over several years. If you have an abnormal Pap smear, you may be scheduled for a repeat Pap smear or colposcopy in a few months. A colposcopy is a close exam of your cervix by special set of binoculars. Samples will be taken of the areas that look abnormal. Examination of the samples will determine if more treatment is needed.

• Treating a pre-cancer after sampling may include:
• waiting and watching with no treatment and more frequent Pap smears
• getting rid of the pre-cancer cells by laser or freezing
• removing the pre-cancer cells with an electric wire or knife or
• surgery
  

Pre-cancer of the Breast

Breast cancers often begin in areas of pre-cancer, called ductal carcinoma in situ or DCIS. These pre-cancers can progress into invasive breast cancer. Once cancers become invasive, they have the potential to spread to other parts of the body or metastasize. Invasive cancer usually forms a mass in the breast that can be felt as a lump or seen as a density on a mammogram. Breast pre-cancer (DCIS) does not usually form lumps, but is often marked by calcifications that can be seen on a mammogram. Complete removal of pre-cancers prevents the development of invasive breast cancer from that area. The smaller an invasive cancer is at detection, the better the chance that it can be completely removed before it spreads.

Oral Pre-cancers

Today a variety of oral precancers are successfully evaluated and managed as a routine facet of oral health care, despite the inevitable controversies and differing definitions. Each of these has its own level of risk and because of the potentially fatal consequences it is extremely important for each clinician to remain knowledgeable and updated on the diagnostic and prognostic features of all premalignancies of the head and neck region. It is especially important to remember that a premalignancy is not guaranteed to eventually transform into cancer, as was believed in the not too distant past. Many, in fact, only do so in a small proportion of cases. This means that the clinician may have to make some very real choices relative to the management of such lesions as leukoplakia, erythroplakia, smokeless tobacco keratosis and lichen planus, and it means that the best choice may not be complete surgical removal, but rather a good, rational follow-up protocol.

A logical review of any controversial issue must begin with a number of definitions. Fortunately, the World Health Organization (WHO) has provided simple but workable definitions of oral precancerous conditions and lesions. The following variations of the WHO definitions are recommended for use with oral precancers:

Precancerous Lesion (Precancer, Premalignancy) -- A benign, morphologically altered tissue which has a greater than normal risk of containing a microscopic focus of cancer at diagnosis or of transforming into a malignancy after diagnosis.

Precancerous Condition -- A disease or patient habit which does not necessarily alter the clinical appearance of local tissue but is known to have a greater than normal risk of precancer or cancer development.

Malignant Potential -- The risk of cancer being present in a precancerous lesion or condition, either at the time of initial diagnosis or at a future date. The potential for mucosa without precancerous lesions or conditions is termed "normal".

Leukoplakia -- A chronic white mucosal macule which cannot be scraped off, cannot be given another specific diagnostic name, and does not typically disappear with removal of known etiologic factors.

Erythroplakia -- A chronic red mucosal macule which cannot be given another specific diagnostic name and cannot be attributed to traumatic, vascular or inflammatory causes.

Smokeless Tobacco Keratosis -- A chronic white or gray/translucent mucosal macule, in an area of smokeless tobacco (ST) contact, which cannot be scraped off and disappears with cessation of the ST habit.

Actinic Keratosis

When doctors speak of precancer of the skin, they are speaking about actinic keratosis, which is the main precancer leading to squamous-cell carcinoma. Again, there is no known precancer for basal-cell carcinoma; the author believes it is best not to consider moles as precancer to melanoma. So, in a nutshell, the only precancer that counts is that leading to squamous-cell carcinoma, a potentially deadly tumor. Please remember that precancers will not kill or harm patients, so do not be misled by material that contradicts this statement.

Precancers require treatment only because they MAY become cancers, or because they are unsightly or crust or do not heal. Only about 5% or 1 in 20 actinic keratoses (precancers) will become squamous-cell cancer. Since it may be difficult to predict which precancer will turn into cancer, doctors do their best to treat as many precancers as possible in order to reduce the chance that one will become malignant. Past treatments for precancers (actinic keratoses) had their limitations.

Barrett's Esophagus

Barrett¡¯s esophagus is a condition of the esophagus (swallowing tube) in which the normal white lining of the esophagus has been replaced by an abnormal red lining called specialized intestinal metaplasia. It occurs in about 10% of people who have chronic or longstanding gastroesophageal reflux disease (heartburn). Barrett¡¯s esophagus is a precancerous lining in which a type of esophageal cancer called adenocarcinoma can develop but the risk of cancer is low in most patients. At the present time, no one can predict which patients with Barrett¡¯s esophagus will develop cancer. It is, therefore, recommended that all patients who have Barrett¡¯s esophagus have their esophagus periodically checked to detect cancer when it is early and curable.

No heartburn medication or anti-reflux surgery has been proven to make Barrett¡¯s esophagus completely disappear or decrease the risk of developing esophageal cancer. The only therapy proven to completely cure Barrett¡¯s esophagus is esophagectomy (surgical removal of the esophagus). Esophagectomy is a surgery that is typically reserved for patients who have high-grade dysplasia or cancer and is not recommended for patients who have Barrett¡¯s esophagus alone. This is because esophagectomy has a much higher rate of death or serious complications as compared to other, more commonly performed, gastrointestinal tract surgeries. In addition, studies indicate that most patients who have Barrett¡¯s esophagus do not develop cancer during follow-up. It is, therefore, recommended that periodic endoscopic biopsy surveillance be performed to detect patients who are at high risk for cancer rather than removing the esophagus of all Barrett¡¯s patients.

Ablation therapy is experimental and may be useful in the treatment of Barrett's esophagus. This therapy involves destruction of the Barrett's lining with replacement by the squamous esophageal lining. At the present time it is unproven to make Barrett's esophagus completely disappear in many patients or to decrease the risk of developing cancer.

At the present time, the main goal of therapy for Barrett¡¯s patients has been to control heartburn symptoms and heal esophageal injury caused by GE reflux of acid. It is basically the same therapy as for patients who have gastroesophageal reflux disease (GERD) without Barrett¡¯s esophagus. There are three main ways to lessen GERD: medical treatment with acid-suppressive agents, anti-reflux surgery and life-style changes without the use of surgery or medicines.

Both successful medical and surgical treatments of GERD control patient symptoms of heartburn and heal esophageal injury and inflammation from acid (esophagitis). Some of the more potent acid-suppressive drugs, such as the proton pump inhibitors, as well as anti-reflux surgery, can cause some of the normal squamous esophageal lining to partially grow back inside of the Barrett¡¯s esophagus lining. In some patients who have a short segment of Barrett¡¯s esophagus, the Barrett¡¯s esophagus may appear to be completely replaced by normal squamous lining. It is unknown whether those patients whose Barrett¡¯s esophagus has apparently disappeared will have Barrett¡¯s tissue detected at a future endoscopy or whether they are safe from cancer.

In some cases, endoscopically normal appearing squamous lining may grow on top of Barrett¡¯s, lining, as seen in biopsies when they are examined under the microscope by the pathologist. Unfortunately, when this occurs, the Barrett¡¯s lining is not only still there, but looks like normal squamous lining through the endoscope. This leads the doctor to think that the Barrett's is gone when it is simply buried beneath normal appearing squamous lining.