11 mistakes women make in middle age

Let’s not kid ourselves. Getting older is a drag, and middle age is particularly fraught with tension.


Do the sexy clothes you wore in the past now seem just plain wrong? Will smoky eye makeup that looks great on 19-year-olds make you appear just plain crazy?

Part of the problem is that aging often requires change, but most women don’t want to move to a frumpy town called Middle Age, where sensible shoes and boring clothes are de rigueur.

Here are the 11 most common mistakes aging women make—and how to avoid them.

Not realizing you need to change
The biggest mistake women make is not doing anything at all. Hair, makeup, and clothing that made you look fantastic in your younger years, often won’t cut it as you grow older.

If you want to age gracefully, you’ll need to make some changes.

“Many women keep doing the same things they’ve been doing for decades, which very often no longer works and may not be as flattering for a woman over 50,” says Barbara Grufferman, author of The Best of Everything After 50: The Experts’ Guide to Style, Sex, Health, Money, and More.

“They often don’t even realize they are making mistakes, so it’s all about finding what those mistakes are before they can happen.”

Not spending enough on your clothes
Remember the good old days, when you could snag a bikini off the sale rack and look like hot stuff on the beach? Unfortunately, those days are gone. (Unless you’re Madonna, Helen Mirren, or happen to look like them.)

The rest of us need to invest in clothing that’s a bit more, well, constructed. Think Lycra panels, butt-boosting jeans, and Spanx.

It’s a challenge to find flattering clothes at any age, but it’s even harder in middle age. You’ll probably need to fork over more dough for body-squeezing swimsuits and well-fitted business clothes that do the trick.

Health.com: The best jeans for your body

Comparing yourself to you in your 20s
Have your kids ever asked, “Who’s that pretty lady in your photo album?” You’re not alone.

Few people look as attractive in middle age as they did in their younger years. So take a walk down memory lane if you must, but don’t get depressed if you run into your younger self.

The goal is to look as good as you can—and be as healthy as you can—not recreate the body and face you had decades ago.

Skipping exercise
Tempted to stop working out as you get older? (Or use it as another excuse not to start?) Sorry, that won’t cut it.

You’ll have to exercise despite the aches and pains of middle age—the bum knee, tricky back, or it-just-makes-me-feel-like-hell feeling.

Exercising can actually relieve pain, and stave off health problems in coming years, such as creeping weight gain, diabetes, heart disease, or dementia.

If you can manage a marathon, great. If not, now is the time to check out the gym pool, start taking yoga, or fall in love with power walking.

Health.com: Your 50s strength workout

Not getting enough sleep
Gone are the days when you could stay up all night and still make it to work with a glowing complexion and a spring in your step.


The fact is, you may have heard a “you look tired” comment even after a good night’s sleep. (It’s OK to grit your teeth on that one.)

While it may be tempting to shortchange sleep, particularly if you’re juggling parent- and child-care duties, this may be one more thing you need to change.

Fewer hours of sleep are more likely to show up on your face, true. But it’s also linked to a greater risk of diabetes and other health problems, which become even more important as you age.

Health.com: 8 things keeping you up at night

Ignoring your teeth
You may be focusing on your wrinkles or thinning hair, but don’t forget to smile at yourself in the mirror.

One thing that can make you appear older is yellowing teeth, but it is about more than just looks. Dental health is closely linked with overall health, and gum disease—which gets more common as you age—has been associated with a higher risk of heart problems.

So don’t skip those visits to the dentist.

Getty Images

Overdoing anti-aging efforts
This is a common mistake made by celebrities and real women alike.

No one likes crow’s-feet or laugh lines, but a frozen Botox face or scary lip plumping isn’t a great look either.

The right skin products (such as those containing retinol) can help diminish fine lines and wrinkles. If you’re not happy with the result, then explore other alternatives—but don’t aim to look like a teen again.

“No wrinkles can be unrealistic and unnatural,” says Grufferman.

Health.com: 14 health products you probably don't need

Thinking there are hair “rules”
Do you have to cut your tresses short or above the shoulders once you’re 50? No, because there aren’t really any hair “rules” for middle-aged women, says Grufferman. “It depends on a woman’s height, shape, lifestyle, and the condition of her hair.”

The fact is that your hair will probably get more gray and thin as you age, and the texture may get coarser as well.

Choose a cut and color that’s flattering, keeping in mind that it probably won’t be the cut and color that worked for you in your 20s and 30s.

Using the wrong makeup
The makeup colors and brands you’ve been wearing for years probably don’t reflect what’s best for your skin anymore.

And resist the urge to slather on heavy-duty powders and concealers to cover up wrinkles and under-eye circles as caked-on or dark makeup can make you seem even older. For a more natural look, Grufferman suggests using a magnifying mirror and having a “lighter touch” when applying. Keep your cosmetic bag current—replace foundations, powders, and concealers every 6 months to a year, and steer clear of dated makeup styles too.

Health.com: The best colors for your complexion

Settling for a boring sex life
Our culture tends to sell the message that young equals sexy, but you don’t have to buy into it.

You should have the confidence and freedom to dress and feel as sexy as you want to, and explore your sexual needs as well.

“Women over 50 can have the best sex of their lives,” Grufferman says. “For many women, it’s the first time they are having sex for fun and enjoyment, not for a result (children)."


 Health.com: 8 reasons sex is better after 50

Wearing the wrong bra
It’s inevitable—gravity has an impact on our bodies. But while you might be saggy where you were once perky, that doesn’t mean you have to stay that way.

“Many women continue to wear the same size and brand they’ve always worn, without considering that our bodies change as we age,” says Grufferman.

The right underwear can help lift and slim your body, so re-evaluate your undergarments and invest in some new pieces. Most large department stores and lingerie shops offer free bra-fitting services.

Endometrial cancer

Endometrial cancer
Definition

Endometrial cancer develops when the cells that make up the inner lining of the uterus (the endometrium) become abnormal and grow uncontrollably.
Description


Endometrial cancer (also called uterine cancer) is the fourth most common type of cancer among women and the most common gynecologic cancer. Approximately 34, 000 women are diagnosed with endometrial cancer each year. In 1998, approximately 6, 300 women died from this cancer. Although endometrial cancer generally occurs in women who have gone through menopause and are 45 years of age or older, 30% of the women with endometrial cancer are younger than 40 years of age. The average age at diagnosis is 60 years old.

The uterus, or womb, is the hollow female organ that supports the development of the unborn baby during pregnancy. The uterus has a thick muscular wall and an inner lining called the endometrium. The endometrium is very sensitive to hormones and it changes daily during the menstrual cycle. The endometrium is designed to provide an ideal environment for the fertilized egg to implant and begin to grow. If pregnancy does not occur, the endometrium is shed causing the menstrual period.

More than 95% of uterine cancers arise in the endometrium. The most common type of uterine cancer is adenocarcinoma. It arises from an abnormal multiplication of endometrial cells (atypical adenomatous hyper-plasia) and is made up of mature, specialized cells (well-differentiated). Less commonly, endometrial cancer arises without a preceding hyperplasia and is made up of poorly differentiated cells. The more common of these types are the papillary serous and clear cell carcinomas. Poorly differentiated endometrial cancers are often associated with a less promising prognosis.
Demographics

The highest incidence of endometrial cancer in the United States is in Caucasians, Hawaiians, Japanese, and African Americans. American Indians, Koreans, and Vietnamese have the lowest incidence. African-American and Hawaiian women are more likely to be diagnosed with advanced cancer and, therefore, have a higher risk of dying from the disease.
Causes and symptoms

Although the exact cause of endometrial cancer is unknown, it is clear that high levels of estrogen, when not balanced by progesterone, can lead to abnormal growth of the endometrium. Factors that increase a woman's risk of developing endometrial cancer are:


    * Age. The risk is considerably higher in women who are over the age of 50 and have gone through menopause.
    * Obesity. Being overweight is a very strong risk factor for this cancer. Fatty tissue can change other normal body chemicals into estrogen, which can promote endometrial cancer.
    * Estrogen replacement therapy. Women receiving estrogen supplements after menopause have a 12 times higher risk of getting endometrial cancer if progesterone is not taken simultaneously.
    * Diabetes. Diabetics have twice the risk of getting this cancer as nondiabetic women. It is not clear if this risk is due to the fact that many diabetics are also obese and hypertensive. One 1998 study found that women who were obese and diabetic were three times more likely to develop endometrial cancer than women who were obese but nondiabetic. This study also found that nonobese diabetics were not at risk of developing endometrial cancer.
    * Hypertension. High blood pressure (or hypertension) is also considered a risk factor for uterine cancer.
    * Irregular menstrual periods. During the menstrual cycle, there is interaction between the hormones estrogen and progesterone. Women who do not ovulate regularly are exposed to high estrogen levels for longer periods of time. If a woman does not ovulate regularly, this delicate balance is upset and may increase her chances of getting uterine cancer.
    * Early first menstruation or late menopause. Having the first period at a young age (a 1997 Pediatrics article identified the mean age of menses as 12.16 years in African-American girls and 12.88 years in white girls) or going through menopause at a late age (over age 51 according to a 2001 Prevention article) seem to put women at a slightly higher risk for developing endome-trial cancer.
    * Tamoxifen . This drug, which is used to treat or prevent breast cancer , increases a woman's chance of developing endometrial cancer. Tamoxifen users tend to have more advanced endometrial cancer with an associated poorer survival rate than those who do not take the drug. In many cases, however, the value of tamoxifen for treating breast cancer and for preventing the cancer from spreading far outweighs the small risk of getting endometrial cancer.
    * Family history. Some studies suggest that endometrial cancer runs in certain families. Women with inherited mutations in the BRCA1 and BRCA2 genes are at a higher risk of developing breast, ovarian, and other gynecologic cancers . Those with the hereditary nonpolyposis colorectal cancer gene have a higher risk of developing endometrial cancer.
    * Breast, ovarian, or colon cancer . Women who have a history of these other types of cancer are at an increased risk of developing endometrial cancer.
    * Low parity or nulliparity. Endometrial cancer is more common in women who have born few (low parity) or no (nulliparity) children. The high levels of progesterone produced during pregnancy has a protective effect against endometrial cancer. The results of one study suggest that nulliparity is associated with a lower survival rate.
    * Infertility. Risk is increased due to nulliparity or the use of fertility drugs.
    * Polycystic ovary syndrome. The increased level of estrogen associated with this abnormality raises the risk of cancers of the breast and endometrium.

The most common symptom of endometrial cancer is unusual vaginal spotting, bleeding or discharge. In women who are near menopause (perimenopausal), symptoms of endometrial cancer could include bleeding between periods (intermenstrual bleeding), heavy bleeding that lasts for more than seven days, or short menstrual cycles (fewer than 21 days). For women who have gone through menopause, any vaginal bleeding or abnormal discharge is suspect. Pain in the pelvic region and the presence of a lump (mass) are symptoms that occur late in the disease.
Diagnosis

If endometrial cancer is suspected, a series of tests will be conducted to confirm the diagnosis. The first step will involve taking a complete personal and family medical history. A physical examination, which will include a thorough pelvic examination, will also be done.

The doctor may order an endometrial biopsy . This is generally performed in the doctor's office and does not require anesthesia. A thin, flexible tube is inserted through the cervix and into the uterus. A small piece of endometrial tissue is removed. The patient may experience some discomfort, which can be minimized by taking an anti-inflammatory medication (like Advil or Motrin) an hour before the procedure.

If an adequate amount of tissue was not obtained by the endometrial biopsy, or if the biopsy tissue looks abnormal but confirmation is needed, the doctor may perform a dilatation and curettage (D & C). This procedure is done in the outpatient surgery department of a hospital and takes about an hour. The patient may be given general anesthesia. The doctor dilates the cervix and uses a special instrument to scrape tissue from inside the uterus.

The tissue that is obtained from the biopsy or the D & C is sent to a laboratory for examination. If cancer is found, then the type of cancer will be determined. The treatment and prognosis depends on the type and stage of the cancer.

Transvaginal ultrasound may be used to measure the thickness of the endometrium. For this painless procedure, a wand-like ultrasound transducer is inserted into the vagina to enable visualization and measurement of the uterus, the thickness of the uterine lining, and other pelvic organs.

Other possible diagnostic procedures include sonohysterography and hysteroscopy. For sonohysteroscopy, a small tube is passed through the cervix and into the uterus. A small amount of a salt water (saline) solution is injected through the tube to open the space within the uterus and allow ultrasound visualization of the endometrium. For hysteroscopy, a wand-like camera is passed through the cervix to allow direct visualization of the endometrium. Both of these procedures cause discomfort, which may be reduced by taking an anti-inflammatory medication prior to the procedure.
Treatment team

The treatment team for endometrial cancer may include a gynecologist, gynecologic oncologist, surgeon, radiation oncologist, gynecologic nurse oncologist, sexual therapist, psychiatrist, psychological counselor, and social worker.
Clinical staging, treatments, and prognosis
Clinical staging

The International Federation of Gynecology and Obstetrics (FIGO) has adopted a staging system for endometrial cancer. The stage of cancer is determined after surgery. Endometrial cancer is categorized into four stages (I, II, III, and IV) which are subdivided (A, B, and possibly C) based on the depth or spread of cancerous tissue. Seventy percent of all uterine cancers are stage I, 10% to 15% are stage II, and the remainder are stages III and IV. The cancer is also graded (G1, G2, and G3) based upon microscopic analysis of the aggressiveness of the cancer cells.

The FIGO stages for endometrial cancer are:

    * Stage I. Cancer is limited to the uterus.
    * Stage II. Cancer involves the uterus and cervix.
    * Stage III. Cancer has spread out of the uterus but is restricted to the pelvic region.
    * Stage IV. Cancer has spread to the bladder, bowel, or other distant locations.


Treatments

The mainstay of treatment for most stages of endometrial cancer is surgery. Radiation therapy , hormonal therapy, and chemotherapy are additional treatments (called adjuvant therapy). The necessity of adjuvant therapy is a controversial topic which should be discussed with the patient's treatment team.
SURGERY.

Most women with endometrial cancer, except those with stage IV disease, are treated with hysterectomy. A simple hysterectomy involves the removal of the uterus. In a bilateral salpingo-oophorectomy with total hysterectomy, the ovaries, fallopian tubes, and uterus are removed. This may be necessary because endometrial cancer often spreads to the ovaries first. The lymph nodes in the pelvic region may also be biopsied or removed to check for metastasis . Hysterectomy is traditionally performed through an incision in the abdomen (laparotomy), however, endoscopic surgery (laparoscopy ) with vaginal hysterectomy is also being used. Women with stage I disease may require no further treatment. However, those with higher grade disease will receive adjuvant therapy.
RADIATION THERAPY.

The decision to use radiation therapy depends on the stage of the disease. Radiation therapy may be used before surgery (preoperatively) and/or after surgery (postoperatively). Radiation given from a machine that is outside the body is called external radiation therapy. Sometimes applicators containing radioactive compounds are placed inside the vagina or uterus. This is called internal radiation therapy or brachytherapy and requires hospitalization.

Side effects are common with radiation therapy. The skin in the treated area may become red and dry. Fatigue , upset stomach, diarrhea , and nausea are also common complaints. Radiation therapy in the pelvic area may cause the vagina to become narrow (vaginal stenosis), making intercourse painful. Premature menopause and some problems with urination may also occur.
CHEMOTHERAPY.

Chemotherapy is usually reserved for women with stage IV or recurrent disease because this therapy is not a very effective treatment for endome-trial cancer. The anticancer drugs are given by mouth or intravenously. Side effects include stomach upset, vomiting, appetite loss (anorexia ), hair loss (alopecia ), mouth or vaginal sores, fatigue, menstrual cycle changes, and premature menopause. There is also an increased chance of infections.
HORMONAL THERAPY.

Hormonal therapy uses drugs like progesterone to slow the growth of endometrial cells. These drugs are usually available as pills. This therapy is usually reserved for women with advanced or recurrent disease. Side effects include fatigue, fluid retention, and appetite and weight changes.
Prognosis

Because it is possible to detect endometrial cancer early, the chances of curing it are excellent. The five year survival rates for endometrial cancer by stage are: 90%, stage I; 60%, stage II; 40%, stage III; and 5%, stage IV. Endometrial cancer most often spreads to the lungs, liver, bones, brain, vagina, and certain lymph nodes.
Alternative and complementary therapies

Although alternative and complementary therapies are used by many cancer patients, very few controlled studies on the effectiveness of such therapies exist. Mind-body techniques such as prayer, biofeedback, visualization, meditation, and yoga, have not shown any effect in reducing cancer but they can reduce stress and lessen some of the side effects of cancer treatments. Clinical studies of hydrazine sulfate found that it had no effect on cancer and even worsened the health and well-being of the study subjects. One clinical study of the drug amygdalin (Laetrile) found that it had no effect on cancer. Laetrile can be toxic and has caused deaths. Shark cartilage, although highly touted as an effective cancer treatment, is an improbable therapy that has not been the subject of clinical study.

The American Cancer Society has found that the "metabolic diets" pose serious risk to the patient. The effectiveness of the macrobiotic, Gerson, and Kelley diets and the Manner metabolic therapy has not been scientifically proven. The FDA was unable to substantiate the anti-cancer claims made about the popular Cancell treatment.

There is no evidence for the effectiveness of most over-the-counter herbal cancer remedies. Some herbals have shown an anticancer effect. As shown in clinical studies, Polysaccharide krestin, from the mushroom Coriolus versicolor, has significant effectiveness against cancer. In a small study, the green alga Chlorella pyrenoidosa has been shown to have anticancer activity. In a few small studies, evening primrose oil has shown some benefit in the treatment of cancer.

For more comprehensive information, the patient should consult the book on complementary and alternative medicine published by the American Cancer Society listed in the Resources section.
Coping with cancer treatment

The patient should consult her treatment team regarding any side effects or complications of treatment. Vaginal stenosis can be prevented and treated by vaginal dilators, gentle douching, and sexual intercourse. A water-soluble lubricant may be used to make sexual intercourse more comfortable. Many of the side effects of chemotherapy can be relieved by medications. Women should consult a psychotherapist and/or join a support group to deal with the emotional consequences of cancer and hysterectomy.
Clinical trials

Because endometrial cancer is a common type of cancer there are many studies underway to optimize its treatment. Women should consult with their treatment team to determine if they are candidates for any ongoing studies.
Prevention

Women (especially postmenopausal women) should report any abnormal vaginal bleeding or discharge to the doctor. Controlling obesity, blood pressure, and diabetes can help to reduce the risk of this disease. Women on estrogen replacement therapy have a substantially reduced risk of endometrial cancer if progestins are taken simultaneously. Long-term use of birth control pills has been shown to reduce the risk of this cancer. Women who have irregular periods may be prescribed birth control pills to help prevent endometrial cancer. Women who are taking tamoxifen and those who carry the hereditary nonpolyposis colorectal cancer gene should be screened regularly, receiving annual pelvic examinations.
Special concerns

Of special concern to the young woman with endometrial cancer is the impact that a hysterectomy will have on her fertility, sexuality , and body image . Depression is common. Symptoms caused by the sudden onset of menopause, due to removal of the ovaries, can be more severe than with natural menopause. Estrogen replacement therapy is not commonly used due to the potential risk of cancer recurrence. Without estrogen replacement, osteoporosis becomes a concern and calcium supplements should be considered. Weight bearing exercise and alendronate (Fosamax) will also decrease the development rate of osteoporosis. Vaginal stenosis following radiation treatment is a concern.
Resources
BOOKS

Bruss, Katherine, Christina Salter, and Esmeralda Galan, eds. American Cancer Society's Guide to Complementary and Alternative Cancer Methods. Atlanta: American Cancer Society, 2000.

Burke, Thomas, Patricia Eifel, and Muggia Franco. "Cancers of the Uterine Body." In Cancer: Principles & Practice of Oncology, ed. Vincent DeVita, Samuel Hellman, and Steven Rosenberg. Philadelphia: Lippincott Williams & Wilkins, 2001, pp.1573- 86.

Long, Harry. "Carcinoma of the Endometrium." In Current Therapy in Cancer, ed. John Foley, Julie Vose, and James Armitage. Philadelphia: W. B. Saunders Company, 1999, pp.162-66.

Primack, Aron. "Complementary/Alternative Therapies in the Prevention and Treatment of Cancer." In Complementary/Alternative Medicine: An Evidence-Based Approach, ed. John Spencer and Joseph Jacobs. St. Louis: Mosby, 1999, pp.123-69.

REMEDY

The manner in which a right is enforced or satisfied by a court when some harm or injury, recognized by society as a wrongful act, is inflicted upon an individual.
The law of remedies is concerned with the character and extent of relief to which an individual who has brought a legal action is entitled once the appropriate court procedure has been followed, and the individual has established that he or she has a substantive right that has been infringed by the defendant.
Categorized according to their purpose, the four basic types of judicial remedies are (1) damages; (2) restitution; (3) coercive remedies; and (4) declaratory remedies.
The remedy of damages is generally intended to compensate the injured party for any harm he or she has suffered. This kind of damages is ordinarily known as compensatory damages. Money is substituted for that which the plaintiff has lost or suffered. Nominal damages, generally a few cents or one dollar, are awarded to protect a right of a plaintiff even though he or she has suffered no actual harm. The theory underlying the award of punitive damages is different since they are imposed upon the defendant in order to deter or punish him or her, rather than to compensate the plaintiff.
The remedy of restitution is designed to restore the plaintiff to the position he or she occupied before his or her rights were violated. It is ordinarily measured by the defendant's gains, as opposed to the plaintiff's losses, in order to prevent the defendant from being unjustly enriched by the wrong. The remedy of restitution can result in either a pecuniary recovery or in the recovery of property.
Coercive remedies are orders by the court to force the defendant to do, or to refrain from doing, something to the plaintiff. An injunction backed by the contempt power is one kind of coercive remedy. When issuing this type of remedy, the court commands the defendant to act, or to refrain from acting, in a certain way. In the event that the defendant willfully disobeys, he or she might be jailed, fined, or otherwise punished for contempt. A decree for specific performance commands the defendant to perform his or her part of a contract after a breach thereof has been established. It is issued only in cases where the subject matter of a contract is unique.
Declaratory remedies are sought when a plaintiff wishes to be made aware of what the law is, what it means, or whether or not it is constitutional, so that he or she will be able to take appropriate action. The main purpose of this kind of remedy is to determine an individual's rights in a particular situation.

Nature of Remedies

Remedies are also categorized as equitable or legal in nature.
Monetary damages awarded to a plaintiff because they adequately compensate him or her for the loss are considered a legal remedy. An equitable remedy is one in which a recovery of money would be an inadequate form of relief.
Courts design equitable remedies to do justice in specific situations where money does not provide complete relief to individuals who have been injured. Injunctions, decrees of specific performance, declaratory judgments, and constructive trusts are typical examples of some kinds of equitable remedies. Restitution is regarded as either a legal or equitable remedy, depending upon the nature of the property restored.
The distinction between legal and equitable remedies originally came about because courts of law only had the power to grant legal remedies, whereas courts of equity granted equitable remedies to do justice in situations where money would be inadequate relief. The courts of law and the courts of equity have merged, but the distinction still has some importance because in a number of courts, a trial by jury is either granted or refused, according to whether the remedy sought is legal or equitable. When a legal remedy is sought, the plaintiff is entitled to a jury trial, but this is not true when an equitable remedy is requested.
Sometimes a plaintiff might have both legal and equitable remedies available for the redress of personal grievances. In such a case, a plaintiff might have to exercise an election of remedies.

Provisional Remedies

A provisional remedy is one that is adapted to meet a specific emergency. It is the temporary process available to the plaintiff in a civil action that protects him or her against loss, irreparable injury, or dissipation of the property while the action is pending. Some types of provisional remedies are injunction, receivership, arrest, attachment, and garnishment.

Liver cancer Definition

Liver cancer
Definition

Liver cancer is a form of cancer with a high mortality rate. Liver cancers can be classified into two types. They are either primary, when the cancer starts in the liver itself, or metastatic, when the cancer has spread to the liver from some other part of the body.
Description and demographics
Primary liver cancer


Primary liver cancer is a relatively rare disease in the United States, representing about 2% of all malignancies and 4% of newly diagnosed cancers. Hepatocellular carcinoma (HCC) is one of the top eight most common cancers in the world. It is, however, much more common outside the United States, representing 10% to 50% of malignancies in Africa and parts of Asia. Rates of HCC in men are at least two to three times higher than for women. In high-risk areas (East and Southeast Asia, sub-Saharan Africa), men are even more likely to have HCC than women.
TYPES OF PRIMARY LIVER CANCER.

In adults, most primary liver cancers belong to one of two types: hepatomas, or hepatocellular carcinomas (HCC), which start in the liver tissue itself; and cholangiomas, or cholangiocarcinomas, which are cancers that develop in the bile ducts inside the liver. About 80% to 90% of primary liver cancers are hepatomas. In the United States, about five persons in every 200, 000 will develop a hepatoma (70% to 75% of cases of primary liver cancers are HCC). In Africa and Asia, over 40 persons in 200, 000 will develop this form of cancer (more than 90% of cases of primary liver are HCC). Two rare types of primary liver cancer are mixed-cell tumors and Kupffer cell sarcomas .

One type of primary liver cancer, called a hepatoblastoma, usually occurs in children younger than four years of age and between the ages of 12 and 15. Unlike liver cancers in adults, hepatoblastomas have a good chance of being treated successfully. Approximately 70% of children with hepatoblastomas experience complete cures. If the tumor is detected early, the survival rate is over 90%.
Metastatic liver cancer


The second major category of liver cancer, metastatic liver cancer, is about 20 times more common in the United States than primary liver cancer. Because blood from all parts of the body must pass through the liver for filtration, cancer cells from other organs and tissues easily reach the liver, where they can lodge and grow into secondary tumors. Primary cancers in the colon, stomach, pancreas, rectum, esophagus, breast, lung, or skin are the most likely to metastasize (spread) to the liver. It is not unusual for the metastatic cancer in the liver to be the first noticeable sign of a cancer that started in another organ. After cirrhosis, metastatic liver cancer is the most common cause of fatal liver disease.
Causes and symptoms
Risk factors

The exact cause of primary liver cancer is still unknown. In adults, however, certain factors are known to place some individuals at higher risk of developing liver cancer. These factors include:

* Male sex.
* Age over 60 years.
* Exposure to substances in the environment that tend to cause cancer (carcinogens). These include: a substance produced by a mold that grows on rice and peanuts (aflatoxin); thorium dioxide, which was once used as a contrast dye for x rays of the liver; vinyl chloride, used in manufacturing plastics; and cigarette smoking.
* Use of oral estrogens for birth control.
* Hereditary hemochromatosis. This is a disorder characterized by abnormally high levels of iron storage in the body. It often develops into cirrhosis.
* Cirrhosis. Hepatomas appear to be a frequent complication of cirrhosis of the liver. Between 30% and 70% of hepatoma patients also have cirrhosis. It is estimated that a patient with cirrhosis has 40 times the chance of developing a hepatoma than a person with a healthy liver.
* Exposure to hepatitis viruses: Hepatitis B (HBV), Hepatitis C (HCV), Hepatitis D (HDV), or Hepatitis G (HGV). It is estimated that 80% of worldwide HCC is associated with chronic HBV infection. In Africa and most of Asia, exposure to hepatitis B is an important factor; in Japan and some Western countries, exposure to hepatitis C is connected with a higher risk of developing liver cancer. In the United States, nearly 25% of patients with liver cancer show evidence of HBV infection. Hepatitis is commonly found among intravenous drug abusers. The increase in HCC incidence in the United States is thought to be due to increasing rates of HBV and HCV infections due to increased sexual promiscuity and illicit drug needle sharing. The association between HDV and HGV and HCC is unclear at this time.

Symptoms of liver cancer

The early symptoms of primary, as well as metastatic, liver cancer are often vague and not unique to liver disorders. The long period between the beginning of the tumor's growth and the first signs of illness is the major reason why the disease has a high mortality rate. At the time of diagnosis, patients are often fatigued, with fever , abdominal pain, and loss of appetite (anorexia ). They may look emaciated and generally ill. As the tumor enlarges, it stretches the membrane surrounding the liver (the capsule), causing pain in the upper abdomen on the right side. The pain may extend into the back and shoulder. Some patients develop a collection of fluid, known as ascites , in the abdominal cavity. Others may show signs of bleeding into the digestive tract. In addition, the tumor may block the ducts of the liver or the gall bladder, leading to jaundice. In patients with jaundice, the whites of the eyes and the skin may turn yellow, and the urine becomes dark-colored.
Diagnosis
Physical examination

If the doctor suspects a diagnosis of liver cancer, he or she will check the patient's history for risk factors and pay close attention to the condition of the patient's abdomen during the physical examination. Masses or lumps in the liver and ascites can often be felt while the patient is lying flat on the examination table. The liver is usually swollen and hard in patients with liver cancer; it may be sore when the doctor presses on it. In some cases, the patient's spleen is also enlarged. The doctor may be able to hear an abnormal sound (bruit) or rubbing noise (friction rub) if he or she uses a stethoscope to listen to the blood vessels that lie near the liver. The noises are caused by the pressure of the tumor on the blood vessels.
Laboratory tests

Blood tests may be used to test liver function or to evaluate risk factors in the patient's history. Between 50% and 75% of primary liver cancer patients have abnormally high blood serum levels of a particular protein (alpha-fetoprotein or AFP). The AFP test, however, cannot be used by itself to confirm a diagnosis of liver cancer, because cirrhosis or chronic hepatitis can also produce high alpha-fetoprotein levels. Tests for alkaline phosphatase, bilirubin, lactic dehydrogenase, and other chemicals indicate that the liver is not functioning normally. About 75% of patients with liver cancer show evidence of hepatitis infection. Again, however, abnormal liver function test results are not specific for liver cancer.
Imaging studies

Imaging studies are useful in locating specific areas of abnormal tissue in the liver. Liver tumors as small as an inch across can now be detected by ultrasound or computed tomography scan (CT scan). Imaging studies, however, cannot tell the difference between a hepatoma and other abnormal masses or lumps of tissue (nodules) in the liver. A sample of liver tissue for biopsy is needed to make the definitive diagnosis of a primary liver cancer. CT or ultrasound can be used to guide the doctor in selecting the best location for obtaining the biopsy sample.

Chest x rays may be used to see whether the liver tumor is primary or has metastasized from a primary tumor in the lungs.
Liver biopsy

Liver biopsy is considered to provide the definite diagnosis of liver cancer. A sample of the liver or tissue fluid is removed with a fine needle and is checked under a microscope for the presence of cancer cells. In about 70% of cases, the biopsy is positive for cancer. In most cases, there is little risk to the patient from the biopsy procedure. In about 0.4% of cases, however, the patient develops a fatal hemorrhage from the biopsy because some tumors are supplied with a large number of blood vessels and bleed very easily.
Laparoscopy

The doctor may also perform a laparoscopy to help in the diagnosis of liver cancer. First, the doctor makes a small cut in the patient's abdomen and inserts a small, lighted tube called a laparoscope to view the area. A small piece of liver tissue is removed and examined under a microscope for the presence of cancer cells.
Clinical staging

Currently, the pathogenesis of HCC is not well understood. It is not clear how the different risk factors for HCC affect each other. In addition, the environmental factors vary from region to region.
Treatment

Treatment of liver cancer is based on several factors, including the type of cancer (primary or metastatic); stage (early or advanced); the location of other primary cancers or metastases in the patient's body; the patient's age; and other coexisting diseases, including cirrhosis. For many patients, treatment of liver cancer is primarily intended to relieve the pain caused by the cancer but cannot cure it.
Surgery

Few liver cancers in adults can be cured by surgery because they are usually too advanced by the time they are discovered. If the cancer is contained within one lobe of the liver, and if the patient does not have either cirrhosis, jaundice, or ascites, surgery is the best treatment option. Patients who can have their entire tumor removed have the best chance for survival. Unfortunately, only about 5% of patients with metastatic cancer (from primary tumors in the colon or rectum) fall into this group. If the entire visible tumor can be removed, about 25% of patients will be cured. The operation that is performed is called a partial hepatectomy, or partial removal of the liver. The surgeon will remove either an entire lobe of the liver (a lobectomy ) or cut out the area around the tumor (a wedge resection).
Chemotherapy

Some patients with metastatic cancer of the liver can have their lives prolonged for a few months by chemotherapy , although cure is not possible. If the tumor cannot be removed by surgery, a tube (catheter) can be placed in the main artery of the liver and an implantable infusion pump can be installed. The pump allows much higher concentrations of the cancer drug to be carried to the tumor than is possible with chemotherapy carried through the bloodstream. The drug that is used for infusion pump therapy is usually floxuridine (FUDR), given for 14-day periods alternating with 14-day rests. Systemic chemotherapy can also be used to treat liver cancer. The medications usually used are 5-fluorouracil (Adrucil, Efudex) or methotrexate (MTX, Mexate). Systemic chemotherapy does not, however, significantly lengthen the patient's survival time.
Radiation therapy

Radiation therapy is the use of high-energy rays or x rays to kill cancer cells or to shrink tumors. Its use inliver cancer, however, is only to give short-term relief from some of the symptoms. Liver cancers are not sensitive to radiation, and radiation therapy will not prolong the patient's life.
Liver transplantation

Removal of the entire liver (total hepatectomy) and liver transplantation can be used to treat liver cancer. However, there is a high risk of tumor recurrence and metastases after transplantation.
Other Therapies


Other therapeutic approaches include:

* Hepatic artery embolization with chemotherapy (chemoembolization).
* Alcohol ablation via ultrasound-guided percutaneous injection.
* Ultrasound-guided cryoablation.
* Immunotherapy with monoclonal antibodies tagged with cytotoxic agents.
* Gene therapy with retroviral vectors containing genes expressing cytotoxic agents.

Prognosis

Liver cancer has a very poor prognosis because it is often not diagnosed until it has metastasized. Fewer than 10% of patients survive three years after the initial diagnosis; the overall five-year survival rate for patients with hepatomas is around 4%. Most patients with primary liver cancer die within several months of diagnosis. Patients with liver cancers that metastasized from cancers in the colon live slightly longer than those whose cancers spread from cancers in the stomach or pancreas.
Alternative and complementary therapies

Many patients find that alternative and complementary therapies help to reduce the stress associated with illness, improve immune function, and boost spirits. While there is no clinical evidence that these therapies specifically combat disease, activities such as biofeedback, relaxation, therapeutic touch, massage therapy and guided imagery have no side effects and have been reported to enhance well-being.

Several other healing therapies are sometimes used as supplemental or replacement cancer treatments, such as antineoplastons, cancell, cartilage (bovine and shark), laetrile, and mistletoe. Many of these therapies have not been the subject of safety and efficacy trials by the National Cancer Institute (NCI). The NCI has conducted trials on cancell, laetrile, and some other alternative therapies and found no anticancer activity. These treatments have varying effectiveness and safety considerations. (Laetrile, for example, has caused deaths and is not available in the U.S.) Patients using any alternative remedy should first consult their doctor in order to prevent harmful side effects or interactions with traditional cancer treatment.
Coping with cancer treatment

Side effects of treatment, nutrition, emotional well-being, and other issues are all parts of coping with cancer. There are many possible side effects for a cancer treatment that include:

* constipation
* delirium
* fatigue
* fever, chills, sweats
* nausea and vomiting
* mouth sores, dry mouth, bleeding gums
* pruritus (itching)
* affected sexuality
* sleep disorders

Anxiety, depression , feelings of loss, post-traumatic stress disorder, affected sexuality, and substance abuse are all possible emotional side-effects. Patients should seek out a support network to help them through treatment. Loss of appetite before, during, and after a treatment can also be of concern. Other complications of coping with cancer treatment include fever and pain.
Clinical trials

There are many clinical trials in place studying new types of radiation therapy and chemotherapy, new drugs and drug combinations, biological therapies, ways of combining various types of treatment for liver cancer, side effect reduction, and quality of life. Information on clinical trials can be acquired from the National Cancer Institute at <http://www.nci.nih.gov> or (800) 4-CANCER.
Prevention

There are no useful strategies at present for preventing metastatic cancers of the liver. Primary liver cancers, however, are 75% to 80% preventable. Current strategies focus on widespread vaccination for hepatitis B, early treatment of hereditary hemochromatosis (a metabolic disorder), and screening of high-risk patients with alpha-fetoprotein testing and ultrasound examinations.

Lifestyle factors that can be modified in order to prevent liver cancer include avoidance of exposure to toxic chemicals and foods harboring molds that produce aflatoxin. Most important, however, is avoidance of alcohol and drug abuse. Alcohol abuse is responsible for 60% to 75% of cases of cirrhosis, which is a major risk factor for eventual development of primary liver cancer. Hepatitis is a widespread disease among persons who abuse intravenous drugs.

See Also CT-guided biopsy; Hepatic arterial infusion; Immunologic therapy; Alcohol consumption
Resources
BOOKS

Berkow, Robert, et al., eds. "Hepatic and Biliary Disorders:Neoplasms of the Liver." In The Merck Manual of Diag nosis and Therapy. Rahway, NJ: Merck Research Laboratories, 1997.

Dollinger, Malin. Everyone's Guide to Cancer Therapy. Kansas City: Somerville House Books Limited, 1994.

Friedman, Lawrence S. "Liver, Biliary Tract, & Pancreas." InCurrent Medical Diagnosis & Treatment 1998. Stamford, CT: Appleton & Lange, 1997.

Isselbacher, K.J., and J.L. Dienstag. "Tumors of the Liver and Biliary Tract." In Harrison's Principles of Internal Medi cine. Fauci, Anthony S., et al., eds. New York:McGraw-Hill, 1998.

Loeb, Stanley, et al., eds. "Liver Cancer." In Professional Guide to Diseases. Springhouse, PA: Springhouse Corporation, 1991.

Rudolph, Rebecca E., and Kris V. Kowdley. "Cirrhosis of the Liver." In Current Diagnosis 9. Conn, Rex B., et al., eds. Philadelphia: W. B. Saunders Company, 1997.

Way, Lawrence W. "Liver." In Current Surgical Diagnosis & Treatment. Stamford, CT: Appleton & Lange, 1994.
PERIODICALS

El-Serag, H.B. "Epidemiology of Hepatocellular Carcinoma"Clinics in Liver Disease (February 2001): 87-107.

Macdonald, G.A. "Pathogenesis of Hepatocellular Carcinoma"Clinical Liver Disease (February 2001): 69-85.

Yu, M.C., et al. "Epidemiology of Hepatocellular Carcinoma"Canadian Journal of Gastroenterology (September 2000):703-9.