Sports Medicine: Just the Facts

102 CANCER AND THE ATHLETE

Brian Whirrett, MD

Kim Harmon, MD

INTRODUCTION

• Cancer in athletes is a topic that has not received
  much attention from the sports medicine community.
  With increasing media coverage of elite athletes and
  their battles with cancer, this topic has become
  increasingly relevant to physicians and their patients.
  Athletes such as Lance Armstrong, Andres Galarraga,
  and Scott Hamilton have brought hope to those bat-
  tling cancer and have inspired many to return to phys-
  ical activity and even elite competition.


• Because of increased numbers of participants in phys-
  ical activity it is more likely that the physician will
  encounter active people and athletes who also have
  neoplastic disease.


• The sports medicine physician needs to be aware of
  the following:
  •Keys to the early diagnosis of cancer in active
  people
  
  
  • Malignancies that present with musculoskeletal
    symptoms
    •Exercise prescription
  
  
  • The effects of exercise on immune function
  
  
  • The benefits of exercise in cancer patients
  
  
  • The value of exercise for the prevention of cancer
  
  
  
  

PREPARTICIPATION EXAMINATIONS

•Keep in mind potential red flags suggesting neoplasm.
•A history of night sweats, fatigue, unintentional
weight loss, decreasing performance, treatment resist-
ant pain, and recurrent infections suggest the need for
further investigation.

• Social history should be reviewed. Tobacco abuse
  can lead to lung or mouth cancers. Environmental
  exposure to chemicals or excessive ultraviolet (UV)
  light should prompt a screen for skin or other malig-
  nancies. Use of anabolic steroids increases the risk of
  hepatoma.
  •A family history of malignancy is important, particu-
  larly in cancers that have a strong genetic link.


• The physical examination should include a skin exam-
  ination to exclude melanoma or other skin cancers.
  Adenopathy, particularly if a mass is enlarging, non-
  tender and fixed, suggests lymphoma or metastatic

disease. Excessive ecchymoses can represent leukemia.

Conjunctival pallor from anemia can be present with

neoplasm that infiltrates the bone marrow, or from

occult blood loss in gastrointestinal (GI) malignancies.

Testicular cancer frequently presents as testicular mass

or swelling. The abdomen should be examined for

masses and hepatomegaly.

MALIGNANCY MASQUERADING

AS MUSCULOSKELETAL PAIN

• There are many medical illnesses that can present as
  musculoskeletal pain. Cancer is no exception and is
  the diagnosis that should remain in the differential.
  •Warning signs that musculoskeletal pain may repre-
  sent a malignancy include musculoskeletal pain unre-
  lieved by rest, unrelenting pain, night pain, or pain
  that does not improve despite appropriate therapy over
  a 4–6-week period.


• Cancers that commonly present as musculoskeletal
  pain (Contran):
  
  
  • Primary osteosarcoma typically occurs in young
    persons under the age of 20 with a male predomi-
    nance. Sixty percent of osteosarcomas arise in the
    knee and should remain in the differential when
    examining nontraumatic knee pain. Fifteen percent
    of osteosarcomas arise in the hip or pelvis and 10%
    in the shoulder. The presenting complaint of patients
    is typically pain, swelling, and tenderness.
  
  
  • Chondrosarcoma comprises 20% of all malignant
    bone tumors. It usually presents in the third decade
    or beyond as an ill-defined pain and mass. The hip,
    pelvis, femoral diaphysis, ribs, and proximal
    humerus are the most common sites.
  
  
  • Ewing’s sarcoma is a neoplasm that afflicts the
    young. It is rare past second or third decade of life
    with a 2:1 male predominance. It commonly pres-
    ents as pain, swelling, and tenderness of the affected
    part, dilated veins, elevated temperature, and sedi-
    mentation rate. It shares many of the same symp-
    toms and signs of osteomyelitis and can be easily
    confused. X-ray changes may be only a small focus
    of ill-defined lucency initially, but eventually will
    progress to a large area of bony lysis. Onion-skin
    layeringof bone is the classic appearance on X-ray
    and is created by subperiosteal new bone formation.
  
  
  • Most giant cell tumors occur between 20 and
    40 years of age with a slight female predominance.
    The usual presentation is nonspecific local pain, ten-
    derness, and functional disability. These tumors may
    grow large enough to produce an externally palpable
    mass. On X-ray a large, lytic soap-bubblelesion is
    seen.
  
  
  
  

598 SECTION 7 • SPECIAL POPULATIONS