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Cancer

What is Cancer?

Humans are made up of cells. Within each cell are genes which direct and control all the cell's functions and determine how and when it divides and grows. Normal cells divide and grow at a controlled rate. How fast or slow a cell divides and grows, and what function it does, depends on the gene within that cell. Cancer begins as a change in the gene of a single normal cell in any part of the body. Once this change takes place, the set of instructions in the gene is changed and the cell no longer acts like it normally does. "Cancer" is actually due to the accumulation of many such errors. Other than the word cancer, several other terms are sometimes used to describe the type of cancer that arises from different tissues in the body.

Tumour : Lump or growth usually from the primary or original site.

Neoplasia : Commonly known as cancer.

Carcinoma : Cancer that originates from epithelial tissues.

Sarcoma : Cancer that originates from connective tissues such as muscles.

Leukaemia and Lymphoma : Cancers that arise from blood and lymphatic cells.

malignant tumour has the ability to spread from its original site into surrounding tissues and to other parts of the body. When that happens, the area where the cancer has invaded will have the same kind of abnormal cell and the same name as the original cancer. For example, if lung cancer spreads to the liver, the cancer cells in the liver are still lung cancer cells. This condition is called metastatic lung cancer. It is not liver cancer.

benign (non-cancerous) tumour does not spread or invade other parts of the body.

TYPES OF CANCER

Anyone affected by cancer would probably want to know more about the disease.  At RGH, we believe in going an extra step to help patients in their cancer treatment by providing support to help patients, caregivers and the public in their journey in battling cancer. We also promote anti-cancer advocacy to the public so that they are aware of cancer and be empowered with knowledge to detect and prevent cancer.

BLADDER CANCER

What is Bladder Cancer?

The bladder is a hollow, muscular organ that lies in the area surrounded by the hipbones, an area called the pelvis. The bladder acts as a reservoir to collect urine from the kidneys. The muscles of the bladder assist in the passing of urine from the lower urinary passage (urethra). The cells lining the bladder can develop abnormally and result in bladder cancer.

How common is Bladder Cancer?

In India, bladder cancer is the ninth most common cancer in men. This cancer usually occurs after the age of 40 years and is seen mostly in people between 50 to 70 years of age. It is about three times more common in men than in women.

Causes and Risks :

This cancer has been associated with smoking, the exposure to certain chemicals related to the aniline dye industry, and chronic infections with schistosomiasis (a parasite) which is common in the Middle East and Africa.

SYMPTOMS

Symptoms and Signs of Bladder Cancer :

The most common symptom is passing out bloodstained urine. This is usually not painful. Blood in the urine associated with pain is usually due to infection or stone disease. Bleeding in bladder cancer is usually more severe and linked with the passing out of blood clots. Occasionally, the cancer can cause blockage in the bladder and give rise to difficulty in passing urine. If there is blood in the urine, especially if a person is above 40 years old, it is important not to rule out bladder cancer.

DIAGNOSIS

Diagnostic :

If bladder cancer is suspected, the doctor will arrange for a cystoscopy, an examination where a flexible fibre-optic tube with a light source is used to look at the urethra and the bladder. This can be done under local or general anaesthetic. Removal of a small amount of tissue from the lining of the bladder can also be done. Scans of the pelvis and abdomen may be arranged to look at the other areas that may be affected by the cancer. A bone scan may be ordered if the bones are suspected to be affected by the cancer.

TREATMENT OPTIONS

Treatment of Bladder Cancer :

Surgery is recommended for most early bladder cancers. The procedure of removing bladder cancer in the early stage using a resectoscope is known as Transurethral Resection of Bladder Tumour (TURBT). This is done under general anaesthesia. After surgery, the patient may pass bloodstained urine for a while and a temporary urinary catheter (flexible tube passed through the urethra and into the bladder) connected to a drainage bag may be fitted.

When the cancer is fairly advanced, the total removal of the bladder is required.

If possible, a new bladder is then made from a person's own intestines if possible. If not, urine is drained into a segment of small intestine that comes out the side of the abdomen i.e. ileostomy.

Radiation therapy may be an alternative to surgery for localised disease. This may also be used if the patient has other illnesses that prevent surgery. Alternatively, it may be used after surgery to try to reduce the chance of cancer recurring. Radiation involves concentrating high-energy rays into an area where the cancer was. Side effects, which are temporary, include redness of the skin, pain on passing urine, passing small amounts of urine frequently, and temporary loss of hair at the radiation site.

Chemotherapy is the use of drugs that kill cancers. Some chemotherapy drugs can be injected directly into the bladder for patients with early bladder cancer to prevent recurrence of cancer. Chemotherapeutic drugs can also be injected into the veins to kill bladder cancer cells that have spread throughout the body and to slow down the growth of the cancer. Side effects of chemotherapy injected into the hand veins include temporary nausea and vomiting, mouth ulcers, hair loss, loss of appetite and tiredness.

Immunotherapy can be used to boost the body's immune system. The anti-tuberculosis vaccine, BCG, injected into the bladder, has been effective in treating high risk superficial bladder cancers. Treatment depends on many factors, including the stage of the cancer, the type of bladder cancer, and the patient's age and general health.

Prognosis of Bladder Cancer

Clinical examinations, x-rays and pathology reports all help the medical team decide the stage of cancer and what the next course of action should be. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with bladder cancer can be good.

Frequently Asked Questions :

How can I prevent bladder cancer?

If your occupation requires exposure to chemicals that are known to cause bladder cancer (such as aniline dye), protective clothing may be beneficial. Smoking doubles the risk of developing bladder cancer. Therefore, the risk is reduced if you do not smoke.

Is there any reliable test that can pick up bladder cancer early?

It is important for a person to seek medical attention early if there is blood in the urine or unexplained or long standing bladder infection. The confirmatory test for bladder cancer is cystoscopy and biopsy of abnormal areas. People who have high exposure to chemicals that cause bladder cancer may be routinely tested.

BREAST CANCER

Overview

What is Breast Cancer?

Breast cancer arises from a malignant tumour. It occurs when breast cells become abnormal and divide without control or order. Normal cells divide and produce in an orderly manner. Sometimes this orderly process is disrupted and cells grow and divide out of control, producing extra tissue to form a mass or lump called a tumour. A tumour can be benign (non-cancerous) or malignant (cancerous). The breasts are made up mainly of fat cells and gland cells. Milk-producing glands in the breast are made up of individual cells which normally reproduce under the control of hormones. Sometimes this process of reproduction goes out of control and an abnormal glandular structure develops. This is the beginning of cancer. The majority of breast cancers start in the milk ducts. A small number start in the milk sacs or lobules.

How common is Breast Cancer?

Breast cancer is now the most common cancer in most cities in India, and 2nd most common in the rural areas. Breast Cancer accounts for 25% to 32% of all female cancers in India. This implies, practically, one fourth (or even approaching one thirds) of all female cancer cases are breast cancers.

Breast cancer is the commonest cancer in women in Kolkata. Breast cancer accounts for 25.4% of all cancers in women in Kolkata.  50% of all cases are in the age group of 25 to 50 years.

Age of Onset

The risk of breast cancer increases with age. Most women who are diagnosed to have breast cancer are older than 40 years old, but younger women may also be affected.

CAUSES AND RISKS

Breast cancer is often triggered by the repeated monthly cycle of normal female hormones. The length of the fertile period, i.e. from the first period to menopause, is a risk factor. A woman whose menopause occurs at 55 years of age has a significantly greater risk than a woman who menopauses at 45 years of age. Age is also important: having the first completed pregnancy after the age of 30 years increases the risk compared to those who complete the first pregnancy before the age of 30. Likewise, women who have never been pregnant also have a higher risk of getting breast cancer. Breast feeding also protects against breast cancer. Hormone replacement therapy increases the risk of breast cancer and this should be discussed before embarking on the treatment.

Between 5 to 10% of all breast cancers are associated with genetic factors. The genes BRCA1 and BRCA2 have been identified and may be associated with breast cancer occurring in approximately half of all families with a very strong history of breast and/or ovarian cancer.

SYMPTOMS

Symptoms and Signs of Breast Cancer :

About 80% of women with breast cancer first consult their doctor with a symptom they notice themselves. The most common feature is a breast lump. The lump may or may not be painful. Sometimes the nipple may be puckered (indrawn) or bleeding, or there is swelling of the skin of the breast. There may be a discharge from the nipple. Lymph glands of the armpit may also be enlarged. In advanced cases, breast cancer can spread to the liver, lung, bone, or brain.

DIAGNOSIS

Diagnostic Tests :

An x-ray examination called a mammogram and a needle biopsy is necessary when there is a case of a suspicious breast lump. Even if the mammogram returns negative, a biopsy may be needed. A mammogram is an x-ray examination which helps to define the extent of the lump. It is sometimes combined with an ultrasound of the breast to determine if the lump is mainly solid or cystic, i.e. filled with liquid only. The mammogram examination is slightly uncomfortable as the breast is compressed against a metal surface to obtain a good x-ray image. Mammograms are much more useful for screening than for evaluation of symptomatic masses. Even if the mammogram is completely normal, a symptomatic breast mass may still need to be biopsied. A biopsy involves removal of tissue from the breast lump using either a core or skinny needle and syringe. This may be done in the clinic. The tissue is processed and sent to the pathologist, a doctor who will look at the tissue under a microscope. The pathologist will be able to tell if the tissue is cancerous. Mammotome Breast biopsy is a new technology that uses a vacuum-assisted device to obtain a biopsy from non-palpable lesions. This device can either be guided by ultrasound or by X-ray. Small samples of tissue are removed from the breast using a hollow needle which is guided precisely to the suspicious lesion via mammogram. This procedure is minimally invasive as compared to an open surgical biopsy, and it is performed as an outpatient procedure. It can sample tiny x-ray abnormalities, call microcalcifications, making early diagnosis of breast cancer possible. It is done under local anaesthesia and takes about 45 minutes to complete. Once cancer is diagnosed, other tests such as chest x-ray, ultrasound of the liver and bone scan may be required to determine if the cancer has spread to other parts of the body.

TREATMENT OPTIONS

Treatment of Breast Cancer

Surgery is the usual initial treatment of breast cancer. A desirable aim of surgical treatment is to conserve the breast if possible, and this involves removing the cancer with the safest minimal amount of surrounding tissue (i.e. wide local excision). For some patients, this is not possible, and total removal of the affected breast and underlying muscles, (i.e. mastectomy), is required. The lymph glands under the armpit may be entirely removed at the time of surgery. (i.e. axillary clearance) or, alternatively, a dye may be injected into the region of the primary tumour to determine the most informative single gland to remove (sentinel mode sampling). This is important to predict the likeliness of recurrence of the cancer.

Radiotherapy after surgery may be recommended to treat cancer cells left in the remaining breast tissue which may cause the cancer to recur in the breast (i.e. local recurrence). Radiotherapy to the chest usually takes place over 5 weeks. Radiotherapy is almost always recommended if only a wide excision of the cancer is performed.

Chemotherapy aims to prevent cancer recurrence in tissues that are distant from the breast. Chemotherapy is usually administered to younger women and it is given over 3 to 6 months. There may be mild nausea or vomiting, hair loss, lethargy or tiredness, and loss of appetite. Most women can continue working during this period. The choice of recommended drugs will depend on the person's general health and other medical problems, stage of cancer, and other risk factors. Some breast cancers have special protein receptors on the cancer cells, such as oestrogen and progesterone receptors, and HER2/neu receptor. Patients whose breast cancers have oestrogen or progesterone receptors are more likely to benefit from additional hormonal treatment. For patients with advanced breast cancer where the cancer has HER2/neu receptors, an antibody to the HER2/neu has been developed for therapeutic use. Studies with the HER2/neu antibody are still being carried out. Due to possible damage to the heart, it cannot be considered standard therapy in the adjuvant (prophylactic) setting yet. Sometimes, chemotherapy is given before surgery to shrink the breast cancer before the surgery. This is usually the case if the breast cancer is especially large. In older women who have reached menopause, chemotherapy may not always be necessary; only hormones such as tamoxifen may be given. This is so if the cancer was oestrogen or progesterone receptor positive.

Advanced Breast Cancer

Breast cancer may spread to the lungs, liver, bones or brain, either at the time of diagnosis or years after the original breast cancer has been removed. Treatment options include hormone treatment, chemotherapy, or radiotherapy. 

Prognosis of Breast Cancer

Prognosis means the probable future outcome of an illness based on the relevant facts of the case. All findings from clinical examinations and investigations and pathology reports are important and must be considered together to decide the prognosis of an individual case of breast cancer. 

The doctor looks for the following features:

  • What is the size of the breast cancer? In general, the larger the cancer, the more likely the cancer will recur. The size of the breast cancer also influences whether breast conservation is an option.
  • How many of the lymph glands in the armpit were involved? The likeliness of the cancer recurring is increased if more lymph glands are affected.
  • Did the pathologist see high risk features such as involvement of the blood vessels or lymph channels in the resected specimen? Were the cancerous cells mature or immature?

Frequently Asked Questions About Breast Cancer

1. Can an injury to the breast cause cancer?

An injury to the breast cannot cause cancer. When the body tries to heal the bruise, it can develop scar tissue. This scar tissue can be mistaken as cancer on mammogram. However, symptoms of injury should subside within a month. If you are worried, seek confirmation from your doctor.

2. Are most breast lumps caused by cancer?

No. Only one lump out of every 10 will be cancerous. This means that 90% of all breast lumps are not cancer. However, the chance of a lump being cancerous increases as you get older. Some women do not have a definite lump, but can feel areas of general ‘lumpiness’ in their breasts. Often, your doctor will be able to reassure you that this is normal but it is important that you ask your doctor to check thoroughly for any change.

3. Can a benign (non-cancerous) lump turn into cancer?

The chances of cancer developing in a benign lump may be no different than in any other part of the breast. However, it is very important for you to make sure that the lump is non-cancerous in the first place.

4. If I have a benign breast problem, am I more likely to get breast cancer?

Occasionally, the risk is slightly higher in some women with particular benign breast problems. However, you will need to talk this over with your doctor.

5. Do benign problems come back?

Generally, no. However, a small number of women will develop new benign lumps in the future.

6. I felt a lump in my breast, but it didn’t show up in the mammogram. Does that mean I don’t have cancer?

A lot of women who find lumps in their breasts get frightened and they go for a mammogram. When nothing shows up, they’re very happy because they assume it’s not cancer. No test is perfect. Ask your doctor to conduct more tests and find out the cause of the lumps. Even though many breast lumps are not cancerous, you should still bring it to your doctor’s attention.

7. What if the lump turns out to be cancer?

If breast cancer is detected early, it has a better chance of being cured. You will need to discuss the diagnosis and the best treatment options with your treating doctor.

8.  What should I do if my doctor says my breast problem is nothing to worry about but I still feel concerned?

If your doctor has suggested your problem is hormonal, you may wish to wait until after your next period to see if the problem is still there. If it persists or if you are still concerned, you may wish to go back to your doctor or seek a second opinion.

9. What if there is a history of breast cancer in my family?

Women who have a strong family history of breast cancer, such as a mother and/or sister who developed breast cancer before menopause, may be at increased risk of getting breast cancer. If you are concerned about a family history of breast cancer, talk with your doctor. You may also wish to consult a breast specialist.

10. Will I still have my menstrual periods after breast cancer treatment?

Treatment with chemotherapy and hormonal therapy may cause changes in your menstrual cycle, resulting in irregular menstruation or early menopause. If you are already reaching menopause, your menstrual periods may not return.

11. Can I become pregnant when I have breast cancer?>

The belief is that changing levels of female hormones during pregnancy could encourage the recurrence of breast cancer. However, there is no data to show that this is so. Some doctors will advise you to wait one or two years after completion of treatment before attempting to conceive. Nevertheless, do discuss with your doctor before planning to conceive.

12. When is a mastectomy recommended?

Some women do better cosmetically with a mastectomy than with the removal of just the lump, since breast reconstruction is now available using tissue expanders or skin flaps. Your surgeon will be able to advise if you are suitable for breast reconstruction.

Early Detection & Prevention

1. If I go for mammogram screening regularly, will I be exposed to dangerous levels of radiation?

Radiation exposure from modern mammogram equipment is believed to be safe.

2. I have a lump in my breast. I am frightened to see the doctor in case it is cancer.

Although your worry is understandable, you should see your family doctor as soon as possible. The great majority of breast lumps are not cancerous. 

3. My mother / aunt died of breast cancer. Am I likely to get breast cancer too?

A small proportion of breast cancer is linked to factors that can be inherited from one generation to the next. Depending upon the number of close relatives affected, you may have a greater chance than a woman who does not have a family history of breast cancer. Most family doctors or hospitals will provide information on breast self-examination and mammogram screenings.

Treatment

1. I have been diagnosed to have breast cancer. Will I get better?

Many women who have had breast cancer live a normal lifespan. Feel free to discuss your own prognosis with your doctor.

2. Will I need to undergo mastectomy?

This depends on the size, position and type of your breast cancer as well as the size of your breast.

3. Does radiotherapy or chemotherapy cause disfigurement and long-term damage?

It is uncommon for women to experience lasting damage from modern radiotherapy techniques. Most chemotherapy side-effects are short-term. Nausea and vomiting are controlled in most patients. Hair loss is still common, and you may require a temporary wig. Your periods may disappear during chemotherapy but may return when you complete chemotherapy. However, for women in their late 30s and 40s, menopause may occur early, perhaps increasing the risk of osteoporosis and heart disease. If a fever occurs while you are on chemotherapy, see your doctor immediately, in case antibiotics are needed.

Hormone therapy for Breast Cancer

1. Why do I need hormone therapy?

Normal female hormones like oestrogen may promote growth of normal healthy breast tissue, but may also accelerate the growth and recurrence of certain breast cancers. Drugs that slow breast cancer growth by interfering with normal female hormone action are generically called hormone therapy. Some breast cancers need the hormone, oestrogen, to grow. Hormone therapy can prevent your body’s natural hormones from activating growth or spread of cancer cells.

2. What drug will I be given? What does it do?

The most common drug used for hormone therapy for breast cancer is the oral tablet, tamoxifen, which stops the action of oestrogen.

3. Will I have any side effects? What can I do about them?

You may experience any of the following common side effects:

  • Hot flushes/sweats. Wear a thin layer of clothing to keep cool when hot flushes occur.
  • Vaginal irritation. Some women experience vaginal dryness or discharge. Notify your doctor who can recommend a non-oestrogen cream or lubricant.
  • Irregular menstrual periods

Some pre-menopausal women experience irregular periods. Some women may find that once they stop taking tamoxifen, their menstrual cycle becomes regular again.

Other less common side-effects are depression, mood swings and a slightly increased chance of developing cancer of the uterus and deep vein thrombosis. Regular gynaecological checkups are recommended.

4.  How long will I be on hormonal treatment?

When used to treat early breast cancer, tamoxifen is most often prescribed for 5 years. Patients with advanced disease may take it for varying lengths of time depending on their response to treatment.

5. Why do some women need hormonal treatment while others do not?

Many breast cancers have ‘receptors’ for oestrogen and progesterone. Receptors are proteins on the surface of the cancer cells to which specific hormones (e.g. oestrogen or progesterone) attach themselves. If the cancer has oestrogen or progesterone receptors, it is likely that hormonal treatment would benefit this group of women.

Prosthesis

1. What choice of prosthesis (breast forms) do I have?

There is a wide range available. The type of breast form you require will depend on your needs. It should closely simulate the weight and shape of a natural breast and your other breast. If you need advice, speak with your Breast Care Nurse.

2. Can the prosthesis be washed? How do I take care of it?

Yes, the prosthesis can be washed. Instructions on the care of the prosthesis can be found in the box when you purchase one. You should also place the prosthesis in the box when you are not using it.

Breast Reconstruction

1. What is a Breast Reconstruction?

Breast reconstruction is an operation to create a new breast to replace the breast which has been removed. Breast reconstruction does not affect breast cancer survival or treatment. The procedure can be performed at the same time as the mastectomy or at a later date. The breast can be reconstructed using an implant such as silicone, normal saline or tissue from your own body. This procedure requires further discussion with your surgeon. 

2. When can breast reconstruction be done?

There are differing opinions on this. It can be done at the time of mastectomy, some months afterwards or even years later. The timing may depend on the type of breast cancer you have, whether you need further treatment (e.g. chemotherapy), how you feel about the loss of your breast or breasts, your general health, and other concerns such as costs. Talk over these issues with your breast surgeon and plastic surgeon. You may wish to ask for a second opinion if you would like one.

3. Can I exercise after breast reconstruction?

It will be helpful to stay active and to exercise regularly if you can. Light exercise, such as walking after surgery, can assist in the recovery process. The amount and type of exercise will depend on what you are used to and how well you feel. It is best to discuss your concerns with your doctor. 

4. Do I need to go for regular breast screening after a reconstruction?

It is important to have regular scheduled mammograms on the opposite breast. Breast self examination should continue. Check both the remaining and the reconstructed breast at the same time each month. You will learn what is normal for you since the breast reconstruction. The reconstructed breast will feel different and the other breast may have changed too.

BREAST FEEDING

1. After being diagnosed with breast cancer, can I still breastfeed my baby?

You can still breastfeed your baby from the unaffected breast. It is not advisable to breastfeed your baby on the breast that is affected by cancer, as it will not be able to produce adequate milk.

2. Can I breastfeed after lumpectomy and radiation therapy?

Yes, you can. Lumpectomy is not so extensive that it will affect your breastfeeding capacity, but radiation therapy will. The breast treated with radiation may go through the same changes as the normal one during pregnancy, but it will produce little or no milk. You can, however, breastfeed your baby with the other breast. 

3. Can I breastfeed after mastectomy?

Yes, you can still breastfeed your baby with the other breast. Frequent nursing will be necessary at first so as to build up a good supply of milk. 

4. Will I be able to breastfeed after a biopsy?

Yes. A biopsy will not interfere with your ability to breastfeed. Even if you need a biopsy while you are breastfeeding, you can still continue to breast-feed. However, you will need to discuss this with your doctor.

Arm Exercises

1. Why do I need to exercise?

You are encouraged to exercise your affected arm soon after your operation to prevent stiffness of the shoulder joint.

2. When can I start doing arm exercises?

It is normal to feel tired for a few days after an operation. You can start the exercises as soon as you feel strong enough. This can be as early as the first day after your operation. The sooner you start, the faster you regain your shoulder movements. 

BRAIN CANCER

What is Brain Cancer?

Brain cancers are generally named after the tissue which they originate from. Majority are glima arising from glial cells in the brain. These include astrocytomas, oligodendrogliomas, ependymomas and mixed cell type gliomas. The other forms of brain cancers are meningiomas, medulloblastomas, chordomas and central nervous system lymphomas.

Brain cancers can be fast growing (high grade), such as glioblastoma multiforme or slow growing (low grade), such as pilocytic astrocytoma.

Cancers from other organs can spread to the brain and are called brain metastases. Brain metastases comprise cancer cells from the original site of cancer, such as lung cancer cells and breast cancer cells.

How common is Brain Cancer?

In India, every year 40,000-50,000 persons are diagnosed with brain tumour. Of these 20 per cent are children.

Age of Onset

Infants have been reported to have brain cancers as well. However, the risk increases after the age of 35 years. During the childhood years, primary brain and spinal cord cancers are the second leading cause of death from cancer.

Causes and Risks

Little is known regarding the cause of brain cancer. These cancers are characterised by a variety of appearances at surgery, under the microscope and by gene analysis.

SYMPTOMS

Symptoms and Signs of Brain Cancer :

Adults with brain cancers are usually diagnosed after they developed fits or seizures. Other signs and symptoms that suggest increased pressure within the skull include persistent headaches associated with vomiting and double vision. Pressure builds up within the skull because the skull is a bony structure that cannot expand. A cancer growing within the brain inside the skull causes pressure to increase. Other patients may develop weakness of one side of their body that is similar to a stroke.

DIAGNOSIS

Diagnostic Tests:

Computerised scans (CT) and magnetic resonance scans (MRI) of the brain are able to detect most brain cancers. These scans may also determine if there is increased pressure within the skull. The exact type of cancer will be determined after a biopsy of the cancer. Sometimes, because of the position of the cancer, a biopsy is not attempted because the risk of causing damage to neighbouring important structures is very high.

TREATMENT OPTIONS

Treatment of Brain Cancer :

Surgery reduces the amount of cancerous brain cells and also provides the pathologist (a doctor who looks at tissues under the microscope) with tissue to diagnose the exact type of brain cancer. Patients who have increased pressure within the skull because of the brain cancer sometimes need to have a shunt put in surgically leading from within the skull to the abdomen. This shunt drains some of the fluid within the skull and therefore reduces some of the pressure within the skull.

Radiotherapy is often recommended once the diagnosis of brain cancer is made. Radiotherapy consists of high-energy rays directed onto the cancer and the surrounding tissues. Patients may experience hair loss and some lethargy during the treatment period.

Chemotherapy is not always used. Fast growing brain cancers respond better to chemotherapy than slow growing brain cancers. Patients who have recurrence after surgery and radiotherapy or patients whose cancers have not responded well to radiotherapy are recommended to go for chemotherapy. Chemotherapy drugs are given orally as well as by injections.

Prognosis of Brain Cancer

Clinical examinations, x-rays and pathology reports all help the medical team decide what the progress of an individual case of brain cancer may be. The appropriate course of treatment will then be put into action. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with brain cancer is reasonably positive. The doctor looks for certain features. Young patients survive longer than older patients with brain cancer. Other features that are important are the patient's exact type of brain cancer, the extent of brain function affected by the cancer and whether the cancer can be operated on.

Frequently Asked Questions :

I have headaches all the time. Could I be suffering from brain cancer?

Headaches have many causes, such as stress, eyesight problems, and migraine. Seek medical help if there are worrisome symptoms, such as vomiting, double vision, weakness on one side of the body, seizures or if the headache is getting progressively worse.

My mother had breast cancer. Now she has brain cancer. Why does she have so many illnesses? Will she die soon?

When breast cancer spreads to the brain, the cancer cells there, are still breast cancer cells. It is an advanced stage of breast cancer. With appropriate treatment, some of her symptoms may be controlled. Cancer that has spread to the brain does not necessarily mean that it is immediately life-threatening if appropriate treatment is sought.

CERVIX CANCER

What is Cervical Cancer?

The cervix is the lower part of the uterus (womb). Cancers that arise in the cervix are potentially curable if detected in the early stage. Therefore, early detection is the key to improving survival. Most cervical cancers are the type called squamous cell carcinomas.

How common is Cervical Cancer?

Cervical cancer ranks as the second most frequent cancer among women in India and the second most frequent cancer among women between 15 and 44 years of age.

Age of Onset

Pre-invasive cancer often occurs in women in their late 20’s to 30’s. These are termed as Cervical Intraepithelial Neoplasia (CIN). These are changes in the lining of the cervix which can lead to cervical cancer. Over time, these pre-cancerous lesions can progress and become invasive cancer if left untreated.

Causes and Risks

Infection with Human Papillomavirus (HPV) is the most common cause or risk factor for cervical cancer. These viruses are transmitted during sexual intercourse, as well as via oral or anal sex. Any female who has ever been sexually active is at potential risk. 

Other risk factors include:

  • Onset of sexual activity before age 20
  • Multiple sexual partners
  • A history of sexually transmitted infections
  • A male sexual partner with a history of sexually transmitted infections and or extramarital sexual activity
  • A male sexual partner with sexual partner(s) with previous cancer of the cervix has been established as a potential risk
  • Cigarette smoking is a co-factor associated with an increased incidence of cervix cancer.

SYMPTOMS

Symptoms and Signs of Cervical Cancer

Abnormal bleeding from the vagina signals the need for an immediate examination. Abnormal bleeding includes bleeding after sexual intercourse or bleeding between menstrual periods. Late symptoms that occur when the cancer is advanced include lower back pain, pelvic pain, weight loss and leg swelling.

DIAGNOSIS

Diagnostic Tests:

Cervical cancer screening with a Pap smear should start as soon as a woman becomes sexually active. This should be performed at 1-3 yearly intervals depending on the age and the number of normal Pap smears. During this examination, a scraping of cells from the surface of the cervix is obtained during a vaginal examination. This is a quick, simple and painless test.

If the Pap smear has abnormal cells, a diagnostic procedure called colposcopy (i.e. Examination of the cervix with a microscope) is done. Certain chemicals may be applied onto the cervix to help pick up abnormal areas. These abnormal areas are then biopsied and examined under a microscope by the pathologist (a doctor who examines these tissues under a microscope).

If cervical cancer is confirmed on biopsy, other tests will be scheduled. These include radiological tests such as a chest x-ray and CT-scan or MRI of the abdomen and pelvis to exclude any regional or distant spread of the cancer. Examination of the pelvis under general anaesthesia is often scheduled to determine the extent of the cancer.

TREATMENT OPTIONS

Treatment of Pre-invasive and Invasive Cervical Cancer

For pre-invasive disease, the treatment is the local removal of the abnormal lining of the cervix by local excision procedures or ablative procedures. Local excision techniques include knife or laser cone biopsies or Loop Electrosurgical Excision Procedures (LEEP). Ablative techniques include laser vaporization or cold coagulation. The technique of choice has to be discussed with the attending doctor. However, the successful treatment of pre-cancer of the cervix almost certainly prevents cancer of the cervix from occurring.

For early invasive cancer of the cervix, a cure can be achieved with either surgery (removal of the uterus i.e hysterectomy, and surrounding tissue, including lymph nodes) or radiotherapy, which is often given with chemotherapy.

For advanced stage cervical cancer where surgery is not possible, concurrent chemo-radiotherapy or radiotherapy is the treatment of choice. Radiotherapy is often given in 2 ways. One method is with external beam radiotherapy and the other is internal beam radiotherapy.

Prognosis of Cervical Cancer

The prognosis for early stage cervical cancer is very good with 5 year survival between 80% to 95%. However, for advanced stage cervical cancer, the 5 year survival rate is less than 40%.

Is prevention possible?

Yes, primary prevention of cervical cancer is now available in the form of vaccines. In India, the two globally licensed vaccines available are Cervarix (Bivalent vaccine) and Gardasil (Quadrivalent vaccine). Both vaccines have been shown to be efficacious in protection against HPV 16 and 18, which cause up to 70% of cervical cancers. All women of reproductive age are encouraged to vaccinate themselves against this preventable cancer. However, as some women may still develop cervical cancer after vaccination, Pap smear test screening is still recommended.

Frequently Asked Questions :

I heard that the pelvic examination may be uncomfortable. Are there alternatives to detect early cervical cancer?

Although uncomfortable, the pelvic examination and Pap smear are still reliable tests for early detection of cervical cancer. All sexually active women are advised to undergo these tests once every year or as instructed by your doctor

I only have one sexual partner. Must I still undergo the Pap smear?

All women who have ever had sexual relationships are advised to undergo a Pap smear test at least once in 3 years or as instructed by your doctor. Cervical cancer, when detected early, is highly treatable.

I have been diagnosed to have cervical cancer. I need radiotherapy. Does that mean I cannot have sexual intercourse anymore?

Yes, you are still able to have sexual intercourse after radiotherapy. You will be taught methods to keep the vagina lubricated and how to prevent vaginal tightness so that sexual intercourse will not be difficult or painful.

Is cervical cancer contagious?

Cervical cancer itself is not contagious. However, the virus that is thought to cause the cancer can be transmitted from one person to another during sexual intercourse.

COLORECTAL CANCER (COLON CANCER)

What is Colorectal Cancer?

Colorectal cancer is a cancer that develops from the cells of the large intestine. The large intestine consists of the colon and rectum. The rectum comprises the last 15 cm of the large intestine and lies within the pelvis, which consists of the hip bones. This is a very small area and the distance between the cancer and the surrounding normal organs is very short. Hence, the chance of the cancer spreading to neighbouring organs in the pelvis is significantly high.

The colon forms the rest of the large intestine that lies above the level of the hips. It is surrounded by fatty tissue, called omentum, and anchored by more fatty tissue (called mesentery) to the walls of the abdominal cavity. The lymph glands are in the mesentery.

Cancer can develop from the cell-lining of the large intestine. The cancer can cause blockage of the intestine, or bleeding in the faeces.

How common is Colorectal Cancer?

Colorectal cancer is the fourth most common cancer in the world and in India, it is the fifth most common cancer.

Age of Onset

Most persons diagnosed with colorectal cancer are older than 45 years of age. Younger persons, younger than 20 years of age, if diagnosed to have colorectal cancer, are likely to have the hereditary form of colorectal cancer such as familial adenomatous polyposis.

Causes and Risks

The risk of colorectal cancer is increased when there is:

  • A personal history of previous colorectal polyps or colorectal cancer;
  • A personal history of inflammatory bowel disease such as ulcerative colitis;
  • A family history of colorectal cancer and / or familial adenomatous polyposis or hereditary non-polyposis colorectal cancer.

SYMPTOMS

Symptoms and Signs of Colorectum Cancer

Common symptoms that persons have are a change in bowel habits, such as persistent diarrhoea or constipation or a change in the frequency of stools. Passing blood mixed with stools is also a suspicious sign which always requires prompt medical attention.

Other symptoms include persistent ill-defined abdominal discomfort or pain. Occasionally, a mass is felt in the abdomen.

DIAGNOSIS

Diagnostic Tests:

The simplest way to detect a rectal cancer is by insertion of the doctor's finger into the rectum, i.e. a rectal examination. This can be done in the outpatient clinic, takes less than 5 minutes and causes minimal discomfort. However, this detects cancers only in the last 5 to 8cm of the rectum.

For cancers that are more distantly located in the large intestine, sigmoidoscope or colonoscope examination can be performed. These fiber-optic flexible tubes are inserted up the rectum into the colon. Through these scopes, removal of a small piece of growth for testing is possible. Insertion of these scopes are performed with minimal anaesthesia in an outpatient clinic. Although uncomfortable, the procedure lasts less than 30 minutes.

Barium enema is an x-ray examination performed to examine the whole length of the large intestine. A dye is passed through a narrow tube into the rectum and allowed to coat the length of the intestine. Multiple x-ray films are taken on various portions of the large intestine and abnormal areas identified. The doctor may further proceed to do a colonoscopy or a sigmoidoscopy so that a biopsy of these suspicious areas can be done.

TREATMENT OPTIONS

Treatment of Colon Cancer

The mainstay of treatment is surgery. The cancer, its surrounding fat, and lymph glands are removed during surgery. The two ends of the cut section are joined together. If for some reason the colon cannot be joined, an artificial opening for the colon, called a colostomy, may be required. This opening allows waste to be removed from the body when the normal opening cannot be used or has to be removed. A colostomy may be temporary or permanent.

Depending on the stage of the cancer, chemotherapy may be required after surgery to improve a person's chance of cure from the cancer. Chemotherapy involves injections of anti-cancer drugs into a vein on the hand. Chemotherapy, which lasts from 6 to 12 months, usually causes mild mouth ulcers, mild diarrhoea, mild hair loss, possible darkening of complexion, and nausea.

Treatment of Rectal Cancer

Again, the mainstay of treatment is surgery. Due to the position of the rectum in the bony pelvis, the chance of cancer spreading to the surrounding organs, such as bladder, uterus and bone, is high. Even if the cancer was totally removed by surgery, there is concern that undetectable cancer cells may lie in the vicinity since the distance between cancer and normal tissue is so short. Hence, depending on how far the cancer has invaded the surrounding fat and organs, radiation therapy is sometimes used to reduce the size of the colorectal cancer before surgery. More often, it is used after surgery to destroy any remaining cancer cells and prevent the cancer from recurring. 

Radiotherapy involves giving high-energy rays into a small area where the original cancer was. The course of treatment, given daily for 5 minutes, usually lasts 5 to 6 weeks. Side effects which may occur include diarrhoea, tiredness, skin redness and rash. In some women, radiotherapy brings on early menopause.

As with colon cancer, chemotherapy may also be required, after surgery. Radiotherapy may be given together with chemotherapy.

Prognosis of Colorectal Cancer

A prognosis is the probable outcome of an illness based upon all the relevant facts of the case. All findings from clinical examination and x-ray investigations and pathology reports are important and must be considered together to decide what the progress of an individual case of colorectal cancer may be. From this, the appropriate course of treatment can be decided and put into action. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with early colorectal cancer is good.

Frequently Asked Questions :

I have haemorrhoids. Will these become cancerous?

Haemorrhoids are enlarged blood vessels of the rectum. They arise because of constipation or pregnancy. They do not become cancerous. However, they will bleed from time to time and over the years may cause anaemia or a lack of red blood cells which may cause symptoms such as tiredness and breathlessness. Haemorrhoids that bleed, itch or discharge mucus should be attended to by a medical professional. Any bleeding from the back passage requires investigation and should not be assumed to be haemorrhoidal in origin.

My father/uncle was diagnosed to have large intestinal cancer. Am I at higher risk of getting the cancer?

Persons considered to be at high risk of being diagnosed with colorectal cancers are persons with a history of colorectal polyps, previous colorectal cancer, persons with one immediate relative diagnosed to have colorectal cancer before the age of 45 years old, persons with two or three immediate relatives diagnosed with colorectal cancer at any age, and persons with a family member known to have familial adenomatous polyposis.

Any patient with familial adenomatous polyposis is usually informed by his surgeon to send the rest of his family for the screening. This is a hereditary condition where hundreds and thousands of polyps develop in the colon, rectum and occasionally stomach. It is usually present by the teenage years. The risk of developing colorectal cancer from one of these polyps is very high. Very often, the affected person has his colon removed before the development of colon cancer. He or she can still lead a normal life after surgery. The diagnosis of familial adenomatous polyposis is usually made on sigmoidoscopy or colonoscopy. Recently, a blood test that can detect the abnormal gene responsible for this condition has been developed. 

Persons considered to be at high risk of developing colorectal cancer should consider undergoing colonoscopy every 3 years. Persons with a history of colonic polyp should consider colonoscopy and removal of polyps every year until no new polyps develop. Thereafter, colonoscopy should be performed every 3 years.

I am afraid of being diagnosed with colorectal cancer. Should I go for screening?

If you are worried about colorectal cancer, you can discuss the possibility of faecal immunochemical testing with the general practitioner. The most effective screening test is colonoscopy, which is recommended in some countries for routine screening of individuals aged 50 to 70 years old every 3 years.

I have been diagnosed to have colorectal cancer. How long will I live?

Many people who have had colorectal cancer live a normal lifespan. Current treatments offer a good prognosis, but you may require several types of treatment to have the best chance of avoiding recurrence of the cancer.

Kidney Cancer

What is Kidney Cancer?

The two kidneys lie at the flanks of the body just behind the intestines, next to the spine. Kidneys form urine to clear some of the toxins produced by the body. The urine drains from the kidneys into ureters and then into the bladder. From the bladder, urine is passed out of the body. The cells that make up the kidney can become cancerous.

How common is Kidney Cancer?

In India, the estimated incidence of Kidney Cancer among males is about 2/100,000 population and among females is about 1/100,000 population. 

SYMPTOMS

Symptoms and Signs of Kidney Cancer

It is important to seek medical advice if blood is seen in the urine. A bulge may also be noticed on one side of the tummy associated with pain and discomfort. There may also be weight loss or fever.

DIAGNOSIS

Diagnostic Tests:

If kidney cancer is suspected, a scan (such as computed tomography scan) is done to look at the kidneys in detail. If this test confirms abnormalities, surgery or a biopsy (removing a small piece of tissue from the tumour to look at under a microscope) will be required to obtain the diagnosis.

TREATMENT OPTIONS

Treatment of Kidney Cancer

Surgery  is the recommended treatment for early stage kidney cancer. Removal of the kidney is called nephrectomy. A person can live a normal life span with only one kidney if the other kidney is normal. Some patients with symptoms of pain and bleeding with minimal cancer spread elsewhere can also be offered surgery

Sometimes Radiation Therapy is given. High-energy rays are focused onto the kidney cancer to relieve pain when the cancer is advanced and cannot be removed surgically. Another use for radiotherapy to the kidney cancer is to stop bleeding from the cancer. Systemic therapies, which comprise of targeted therapy and immunotherapy, are used in advanced kidney cancer. It is not a cure but can prolong the life of the individual. There are an increasing number of new targeted therapies that have been developed in this setting.

Prognosis of Kidney Cancer

Clinical examinations scans and pathology reports all help the medical team decide what the progress of kidney cancer is. The appropriate course of treatment may then be recommended. The treatment strategy will vary from person to person. Prognosis of kidney cancer depends on the extent of the disease (stage), the state of health of the individual as well as response to treatment.

Frequently Asked Questions :

I have been diagnosed to have advanced kidney cancer. I have read about spontaneous remissions. What does that mean?

Occasionally, patients with advanced kidney cancer involving the lungs, have temporary disappearance of the kidney cancer in the lungs. After a while, the cancer returns. The reason for this is unknown.

My mother has advanced kidney cancer and she is not fit for surgery. Her urine is always heavily bloodstained. What can be done to stop the bleeding?

Radiotherapy to the kidney cancer may be able to stop the bleeding. Bleeding may also be stopped by embolisation. During this procedure, a thin tube is inserted through blood vessels in the groin and threaded up to the bleeding kidney. A gelling agent is injected into the blood vessel that supplies the cancer. This stops bleeding in most patients.

I have bloodstained urine periodically. Although I have seen a doctor on many occasions, only antibiotics have been prescribed. What more can be done?

There are a variety of causes of bloodstained urine, including infection, stone disease, and cancer of the urinary tract. Let your doctor know about your concerns regarding cancer. You may have to be referred to a urologist for further investigations.

Can I live a normal life with one kidney?

Yes, you can survive with one functioning kidney. Even with a slight impairment of functioning of the one kidney, we can still live normally and may not need dialysis.

How can I prevent recurrence of the cancer once I am in remission?

There are no proven recurrence prevention strategies at this point. You should continue with close follow up with your cancer specialist and maintain a healthy lifestyle.

Larynx Cancer

What is Larynx Cancer?

The larynx is the voice box. It is made up of the glottis, which are the vocal cords. The subglottis is the area below the vocal chords, and the supraglottis is the area above the vocal cords. Any of the cells lining the larynx can become cancerous.

How common is Larynx Cancer?

Laryngeal cancer is the seventh most common cause of cancer in males in India. Laryngeal cancer contributes to approximately 3-6% of all cancers in men. Indian studies show tobacco, alcohol, long-term exposure to indoor air pollution, spicy food, and non vegetarian diet as risk factors for laryngeal cancer.

Causes and Risks

Smoking is one of the most common risk factors associated with larynx cancer. Alcohol consumption is also a risk factor. Smokers who also drink alcohol have a much higher risk of developing larynx cancer than persons who only smoke or who only drink alcohol.

SYMPTOMS

Symptoms and Signs of Larynx Cancer

A person should seek early medical attention if he has a persistent hoarse voice or a persistent sore throat, a painless lump in the neck, feels pain on swallowing, has difficulty swallowing, or has noisy breathing known as stridor. As cancer can spread to other organs in the body, symptoms may affect the lungs or bone in the later stage of cancer.

DIAGNOSIS

Diagnostic Tests:

If larynx cancer is suspected, the doctor will examine swelling or lumps in the neck. An angled mirror that faces downwards is placed against the back of the throat (the palate) to examine the voice box and surrounding organs. Alternatively, a flexible tube, less than a centimeter in diameter, is passed into one of the nostrils to the back of the throat to look for lumps or ulcers in the voice box and surrounding areas.

TREATMENT OPTIONS

Treatment of Larynx Cancer

Early stage cancers of the larynx are treated with radiotherapy and this allows the patients to have their voice boxes preserved. 70% to 95% of patients treated this way achieve local control. Surgery can salvage cases where radiotherapy fails. More advanced tumours may be treated with radiotherapy combined with chemotherapy or surgery followed by radiotherapy. Patients who have had their larynxes removed by surgery can continue to speak in one of the following three ways:

  • Oesophageal speech (using air from the stomach)
  • Amplification by an electronic device placed against the neck while speaking or
  • Having a prosthetic device inserted into the tracheostome.

Liver Cancer

What is Liver Cancer?

The liver is one of the major organs of the body, and is vital to live (hence the name “live-r”). It is involved in many processes of the body, such as manufacturing various essential proteins, processing and storing nutrients, destroying toxins and poisons among others. The liver is made up of many different cell types, but the two main ones are liver cells (hepatocytes) and cells lining the bile ducts (cholangiocytes). 

Like any other part of the body, the cells in the liver can undergo changes to form cancer. Liver cells that become cancerous form liver cancer (hepatocellular carcinoma, HCC). Cancerous cells that start from other parts of the body and spread to the liver, for example, colon cancer that has spread, does not constitute liver cancer in the strictest sense. These are known as secondary liver tumours or metastatic cancers to the liver.

How common is Liver Cancer?

The male : female ratio for HCC (hepatocellular carcinoma) in India is 4:1. The age of presentation varies from 40 to 70 years. Liver cancer is the sixth most common cancer worldwide. Liver cancer is mainly an Asian disease, and is common in South-East Asia, China, Japan and Korea. It is also common in parts of Africa and the Mediterranean (especially Italy).

Age of Onset

Liver cancer occurs in persons in the older age group, from 40 to 50 years old. It can affect a younger individual who has contracted chronic hepatitis B or C from birth or in those with certain congenital conditions.

Causes and Risks

The three main causative factors for liver cancer are hepatitis B carrier status, hepatitis C infection and alcoholic liver disease. Other rare causes include poisons (aflatoxin) from fungus growing in badly preserved food (especially grains), congenital conditions (alpha-1 anti-trypsin deficiency), and any cause of liver hardening or cirrhosis (e.g. haemachromatosis).

The risk of an individual with hepatitis B or C of getting liver cancer is 100 times more as compared to an individual without hepatitis B or C. The pattern of liver cancer worldwide follows closely with the pattern of hepatitis B and C infections. In countries where immunization for hepatitis B is available, the number of liver cancers seen per year has also fallen and has also seen a fall in the number of hepatitis B cases. Hepatitis B can be transmitted from an infected mother to her baby during pregnancy. In the adult setting, hepatitis B and C can be transmitted by contact with infected body fluids, for example saliva, blood, sperm and other secretions.

Alcohol is the main cause of liver cancer in the Western population. The liver is damaged by repeated and excessive alcohol abuse leading to liver hardening (cirrhosis) and liver cancer.

SYMPTOMS

Symptoms and Signs of Liver Cancer

The majority of patients with liver cancer have no symptoms. It is very often detected by chance as a result of an ultrasound test or CT scan for other unrelated problems. In some patients there may be vague symptoms of heaviness or discomfort in the right side of the abdomen. Pain and appetite or weight loss are usually late symptoms.

In a small group of patients, liver cancer presents itself as a sudden intense pain in the abdomen as a result of rupture of the tumour. This is usually a bad sign and is related to bleeding of the tumour inside the abdomen.

DIAGNOSIS

Diagnostic Tests:

A simple blood test for alpha-fetoprotein (AFP) may detect liver cancer. Levels below 10 are normal. In up to 30% of patients with liver cancer, the AFP can be normal. Other causes of a raised AFP include early childhood, liver damage from hepatitis, or tumours in the testes. 

The simplest imaging study of the liver is an ultrasound. This has no radiation risk and can be done on a regular basis, especially in individuals who are at risk of liver cancer, for e.g. hepatitis B carriers who are screened regularly for liver cancer. It is however not always accurate and is dependent on the skill of the person doing the ultrasound scan.

A CT scan is a better way of detecting liver cancer and is crucial for planning for treatment. This would be the basic imaging that will be done by the liver surgeon to detect and plan a treatment strategy for liver cancer. In certain cases, a CT scan may not be enough or is inconclusive, and additional investigations like MRI or angiograms may be performed.

A CT scan is a better way of detecting liver cancer and is crucial for planning of treatment. This would be the basic imaging that will be done by the liver surgeon to detect and plan treatment strategies for liver cancer. On occasions, a CT scan may not be enough or is inconclusive, and additional investigations like MRI or PET-CT scans may be performed. An MRI is like a CT scan, but uses magnetic forces instead of radiation.

TREATMENT OPTIONS

Treatment of Liver Cancer

Surgery is the treatment of choice for liver cancer. All other methods have not been shown to be as effective as surgery in treating liver cancer. However, because liver cancer is frequently associated with liver damage (cirrhosis) in the other parts of the liver due to alcohol damage or hepatitis, surgery for liver cancer is difficult or impossible for a large proportion of patients. 

As surgery is the only effective method for treating liver cancer, it is crucial that a person with suspected liver cancer has a proper assessment of his condition by a well-trained liver surgeon to decide if the cancer can be removed. A liver surgeon is known as a hepato-pancreato-biliary (HPB) surgeon. Liver surgery is currently safe and effective in treating liver cancer. 

In selected cases, liver transplant is another surgical option for definitive liver cancer treatment. 

When surgery is not possible, there are other options that may help to control the tumour and attempt to prolong survival time but not “cure” the person. The many options available suggest that no single method is particularly effective. It is better to discuss these options with a trained liver cancer specialist who can advise you on the appropriateness of each method. Some of these options that are available at NCCS include chemotherapy (systemic or local, TACE), alcohol injection, heat-destroying the tumour (radiofrequency ablation, RFA), or using radionuclear material to deliver local radiation. A newer method that is also available involves delivering radiation beads directly to the liver tumour (SIRspheres). 

Prognosis of Liver Cancer

Liver cancer is the third most fatal cancer. If untreated, most patients do not survive beyond 6 months. Surgery is the only method that allows for a reasonable survival beyond 5 years. With curative surgery, the chance of survival beyond 5 years is more than 40%.

New tumour growth is common in liver cancer because of the underlying liver disease (i.e. hepatitis or cirrhosis). There are currently no effective means of preventing this new growth, and close follow-up after surgery is necessary to detect tumour regrowth at an early stage as it can still be treated effectively.

Screening

The risk groups for liver cancer are well defined and screening is targeted at this group. The aim is to try and detect cancer at an early stage when surgery is still possible for a cure. Based on MOH guidelines, patients with established hepatitis B or C carrier status or have liver cirrhosis would benefit from regular AFP estimations and ultrasound examinations. These tests are usually done at 6-monthly intervals depending on the severity of liver damage, i.e. cirrhosis.

Prevention

amily members of patients with hepatitis B are advised to check their hepatitis B status. If they are not-infected and are without protection, they should go for immunization against hepatitis B. Children are currently advised immunization at birth for hepatitis B as part of a national programme. There is currently no immunization for hepatitis C.

As hepatitis B and C are spread by bodily fluids, there is an association with sexual promiscuity and multiple sexual partners, especially with unprotected sex or with sex workers. Intravenous drug abuse using contaminated syringes is a high risk factor for transmission of hepatitis B and C.

Alcohol abuse can lead to liver cirrhosis and this dramatically increases the risk of liver cancer. Therefore, it is wise to drink in moderation.

Frequently Asked Questions :

I have blood relatives with liver cancer. Am I at higher risk of developing liver cancer?

Hepatitis B carriers who have blood relatives diagnosed with liver cancer have a higher risk of developing liver cancer themselves. They should be evaluated and seen regularly by physicians who have a special interest in diseases of the liver (hepatologists).

I developed hepatitis after travelling to a nearby country. Will I develop liver damage?

There are many hepatitis viruses, such as hepatitis A virus, which are spread by eating contaminated food. The hepatitis A virus causes short term liver damage, after which the liver will repair itself and no further damage is done. There are also many other viruses which do not specifically attack the liver, but can cause mild short-term liver infection, such as the dengue virus.

My father had colon cancer. Now he has liver cancer. Why does he have two cancers?

It may be wise to ask your father's physician again what he or she has found in your father. When a patient has colon cancer and this colon cancer later spreads to the liver, the patient is still suffering from colon cancer and not from liver cancer. The cancer cells that are in the liver will behave like colon cancer cells. It is not a new cancer, but rather an advanced stage of colon cancer.

Lung Cancer

What is Lung Cancer?

The lungs are located in the chest and enable us to breathe. When we breathe in, air goes through our nose, down our windpipe (trachea), and into the lungs, where it spreads through tubes called bronchi. Oxygen from the air that we breathe can then pass into the blood and to the rest of the body to allow the body to function normally.

Lung cancer refers to the uncontrolled growth of abnormal cells which come from the lungs, usually from the cells that line the bronchi. The abnormal cells do not carry out the function of normal lung cells. As these abnormal cells grow, they can get bigger and start to interfere with the normal functioning of the lung, they can pass from the original part of the lung to other parts of the body, such as the opposite lung, our lymph nodes, bones, liver etc.

How common is Lung Cancer?

Lung cancer is one of the commonest cancers and cause of cancer related deaths all over the world. In India, lung cancer constitutes 6.9 per cent of all new cancer cases and 9.3 per cent of all cancer related deaths in both sexes, it is the commonest cancer and cause of cancer related mortality in men.

Age of Onset

Most persons diagnosed with lung cancer are older than 40 years of age. However, the disease may begin before this age range.

Causes and Risks

Cigarette smoking is the main cause of lung cancer. The risk of lung cancer developing in a smoker is 15-25 times more than for a non-smoker. The risk of lung cancer is greater with increasing number of years of smoking and with higher number of cigarettes smoked per day. Pipe, cigar and marijuana smoking also increase the risk of lung cancer. Breathing in the smoke of others (called second hand smoke) can increase the risk of developing lung cancer by about 30%. The risk to children of smokers is not yet accurately quantified. 

Exposure to certain workplace chemicals such as asbestos, coal gas, chromium, nickel, arsenic, vinyl chloride, and mustard gas may also increase the risk of lung cancer.

SYMPTOMS

Symptoms and Signs of Lung Cancer

Often, there may be no symptoms of lung cancer, particularly when it is at an early stage. However, common symptoms of lung cancer include:

  • A persistent cough that does not go away or gets worse
  • Blood in sputum
  • Increasing breathlessness
  • Pain in the chest that may be worsened with deep breathing or coughing
  • A change in the voice/ development of a persistent hoarse voice
  • Recurrent infection in the lungs
  • Loss of appetite and/ or unexplained weight loss and fatigue
  • A lump or swelling in the neck (which is due to cancer that has spread to the lymph nodes of the neck)
  • Bone pain, or headache or weakness of the arms or legs (which may be due to the lung cancer spreading to other parts of the body, such as the bones or the brain)

DIAGNOSIS

Diagnostic Tests:

Any persistent cough or change in the nature of the cough, the appearance of blood-stained sputum, or unexplained breathlessness should prompt a person to seek medical advice. Often chest x-rays will then be performed and sputum may be sent for testing for cancer cells or infections, such as tuberculosis. 

If the suspicion of cancer is high, or if the chest x-ray shows any abnormality, a special scan of the lungs, called a CT (computed tomography) scan may be performed to evaluate more accurately for presence of lung cancer. If this scan shows a suspicious mass, a biopsy may be recommended, where a small specimen from this mass is then obtained for examination under a microscope, to look for the presence of cancer cells.

In lung cancer, this biopsy can often be performed in a few different ways, such as passing a needle through the skin into the lung mass under x-ray guidance, or by performing a bronchoscopy examination, where a small tube is introduced through the mouth and into the lung. Small specimens from the suspicious lung mass can be removed for further examination. Alternatively, a biopsy sample may also be taken from the lymph nodes or other areas that the cancer has affected, such as the liver. 

After the diagnosis of lung cancer is made, further genetic tests may be performed on the cancer cells from the biopsy sample, which may help doctors decide which treatment is suitable for the lung cancer.

Lung function tests may be performed to determine how well the lungs are working and determine if it is safe to proceed with treatments such as surgery or radiotherapy to the lungs.

Once cancer is diagnosed, computerised tomography (CT) scans of the chest and liver may be performed to determine if the cancer has spread to other organs, such as the liver or adrenal gland, which is just above the kidneys on both sides. Occasionally, bone scans and CT scans of the brain are also required.

A lung function test, which involves blowing into a large cylinder, may be performed pre-operatively to determine the lung function prior to any surgery discussions.

TYPES OF LUNG CANCER

Types of Lung Cancer and Staging

The two main types of lung cancer are:

  • Non-small cell lung cancer (NSCLC) which is the most common type of lung cancer. 
  • Small cell lung cancer (SCLC) makes up about 10-15% of all lung cancer cases.

Small cell lung cancer is more rapidly growing and spreads earlier to other organs as compared to non-small cell lung cancer. Non-small cell lung cancer generally grows slower than small cell lung cancer and tends to be confined to the lung for a longer period of time.

Once cancer is diagnosed, further scans of the bones, brain and rest of the body may be performed to determine if the cancer has spread to other organs. The results will be reviewed by the doctor to determine the final stage of the lung cancer.

TREATMENT OPTIONS

Treatment of Small Cell Lung Cancer

Chemotherapy is essential in the treatment of small cell lung cancer, due to its tendency to spread early to other organs, such as liver, bone and brain. If the cancer is still localised to one part of the lung and within the lymph nodes of the lung, radiotherapy to the lungs is administered together with chemotherapy. This combination of chemo-radiotherapy has been shown to have better results than just chemotherapy alone for patients with localised cancer. Surgery is usually not recommended for small cell lung cancer. The exact choice of chemotherapy medicine will depend on the person's general health and other prevalent medical problems.

Treatment of Non-Small Cell Lung Cancer

Surgery, radiotherapy, chemotherapy and targeted therapy alone or in combination may be used to treat NSLC. In general, stage I and stage II cancer, where the cancer is localised to one part of the lung only, is usually treated with surgery to remove the lung cancer. Sometimes after surgery, further chemotherapy may be recommended to reduce the change of the cancer from returning.

For patients with stage III lung cancer, where the cancer may be large (>7cm), or have spread to the lymph nodes between both lungs, a combination of chemotherapy and radiotherapy to the lungs may be recommended.

For stage IV lung cancer, where the lung cancer cells have spread to other parts of the lungs and/ or body, further tests of the biopsy specimen to subtype the cancer further may help determine whether chemotherapy or targeted therapy with specific tablets will be more suitable. 

Prognosis of Lung Cancer

Prognosis means the probable outcome of an illness based upon all the relevant facts of the case. The results of patients' clinical examinations, x-ray investigations and biopsy reports are considered together in order to decide what the stage and progress of an individual case of lung cancer may be. From this, the appropriate course of treatment can be decided and put into action. The treatment strategy will vary from person to person.

The doctor looks for the following features:

  • Type of lung cancer (small cell or non-small cell)
  • The stage of the lung cancer, including whether any other parts of the body are affected
  • The size of the lung cancer
  • If surgery is done to remove the cancer, how many of the neighbouring lymph nodes which were involved and were all involved lymph nodes removed at surgery?
  • Patient's general condition, whether he has other medical problems that may affect the ability to treat his lung cancer effectively, for example, fitness for surgery.

Prevention

Avoid active and secondary tobacco smoke exposure. 

Frequently Asked Questions :

I have been smoking for many years? Why should I stop smoking now?

Lung cancer takes years to develop. The risk increases with each year of smoking, and with each cigarette smoked per day. Stopping smoking will reduce the risk of cancer developing. Smoking also increases the risk of other diseases, such as chronic lung disease, heart disease, stroke and other cancers such as head and neck cancers. Stopping smoking will reduce the risk of lung cancer developing as well as reduce the likelihood of developing heart and lung problems. Smoking can also harm your spouse and family members.

How do I stop smoking? How do I stop a family member from smoking?

Smoking cessation clinics are available at many family practitioner's and polyclinics. Avail yourselves to any of these clinics. Giving a family member support will also help him or her to stop smoking.

Lymphoma

What is Lymphoma?

A special type of white blood cell, called lymphocyte, is important for your body's resistance to disease. These cells get exposed to various substances within the body in an attempt to build the immunity. They collect and filter the substances at the Lymph nodes. Lymph nodes are found anywhere in the body, particularly in the neck, armpits, groin, above the heart, around the big blood vessels inside the abdomen. Lymphocytes may also group together in the tonsils, spleen and thymus. Lymphoma is a type of cancer that develops in the lymphocytes in any of these areas.

How common is Lymphoma?

The age-adjusted incidence rates for Lymphoma in men and women in India are 2.9/100,000 and 1.5/100,000, respectively. It is one of the most common cancer seen in children and young adults as well. It affects more men than women. Most adult patients develop lymphoma after the age of 50.

Causes and Risks

There is no specific cause for lymphoma, but it has been closely associated with abnormally decreased immune systems that may be present from birth or associated with viruses such as the AIDS virus.

SYMPTOMS

Symptoms and Signs of Lymphoma

Lymphoma commonly appears as a painless lump that persists or increases in size. A doctor should be seen if there is any painless swelling in the neck, armpits or groin with or without persistent fever, drenching sweats or unexplainable weight loss.

DIAGNOSIS

Diagnostic Tests:

Benign conditions can also cause swelling, so a diagnosis of lymphoma is made only after a biopsy (removal of a piece of tissue) is done and the tissue is examined by a pathologist (a doctor who examines tissue under a microscope).

Once lymphoma is confirmed, further tests, such as scans, biopsy of bone marrow and blood tests may be needed to see how widespread the lymphoma is. Tests of heart function may also be required to see how fit a person is for treatment.

Types of Lymphoma

Lymphomas are broadly divided into Hodgkin's disease and non-Hodgkin's lymphoma, based on the looks under the microscope. There are many types of non-Hodgkin's lymphoma. The size and shape of the cancer cells and arrangement of the cancer cells in the lymph node determine the type of non-Hodgkin's lymphoma. Non-Hodgkin's lymphomas are further divided into aggressive (high grade) or slow-growing (low-grade) groups. Hodgkin's lymphoma develops for a specific abnormal lineage of B-cells. It is diagnosed when these specific cancer cells are present.

TREATMENT OPTIONS

Treatment of Lymphoma

Treatment of lymphoma may require chemotherapy. Chemotherapy drugs are either injected into the hand veins or swallowed as pills. Each course of treatment is given at regulated intervals to kill cancer cells and allow the body to recover. 

Radiation therapy is a localized treatment using high-energy rays to kill lymphoma cells wherever the rays are directed. The area covered may just be the lymph nodes or organ involved by lymphoma or, in some cases, to a wider area encompassing the lymph nodes in the neck, chest and under both armpits. It may be given alone or combined with chemotherapy. (Biological therapy uses products that boost the body's own immune system to fight cancer. It may be used alone or combined with chemotherapy.

Many new developments in the field of biological therapy are emerging. Antibodies to one type of lymphoma have been developed and may be used when conventional treatment is no longer effective. The combined treatment of high dose chemotherapy is being studied for certain patients. Here chemotherapy is given at much higher doses than standard chemotherapy treatment to kill any remaining lymphoma cells. But the high dosage also kills healthy bone marrow that produces white blood cells (infection-fighting cells), red blood cells (cells that carry oxygen), and platelets (cells that prevent bleeding). To help the patient tolerates high dose chemotherapy, stem cells or bone marrow from the patient or donor is collected beforehand. After a patient receives the chemo- therapy, the stem cells or bone marrow is returned to the patient through a drip in a hand vein.

The stage of the lymphoma when diagnosed and whether it is slow growing or aggressive will determine the type of treatment given.

Prognosis of Lung Cancer

Clinical examinations, x-rays and pathology reports, age and overall health status of the patient all help the medical team decide what the progress of an individual case of Lymphoma may be. Then, the appropriate course of treatment will be put into action. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with Lymphoma is good.

Frequently Asked Questions :

Is Lymphoma contagious?

There is no evidence that lymphoma can spread to another person by close contact as it is not a virus or bacteria. It is a collection of cells in the body that has become cancerous.

Why do some lymphomas need to be treated straight away while other lymphomas do not need treatment?

The fast-growing, high grade or aggressive lymphomas can increase in size and sometimes spread over days or weeks, and cause the patient to become very sick. These lymphomas need to be treated within a short period of time to get the disease under control. The slower growing lymphoma may take months or years to grow and may sometimes even disappear without any treatment. They may cause disturbing symptoms to the patient eventually and this is when treatment is started.

NOSE CANCER (NASOPHARYNX CANCER)

What is Nasopharyngeal Cancer?

The area behind the nose and just above the back of the throat is called the nasopharynx. The cells lining the nasopharynx can become cancerous and give rise to nasopharyngeal cancer or NPC.

How common is Nasopharyngeal Cancer?

Nasopharyngeal carcinoma (NPC) is a rare head and neck cancer with an age- standardized ratio being 0.6–2.0/100,000 in males and 0.2–0.8/100,000 females worldwide.

Head and neck cancer is the leading form of cancer in males in India and ranks 5 th for females.

It affects men more frequently than women and it occurs between the ages of 35 to 55 years.

SYMPTOMS

Symptoms and Signs of Nasopharyngeal Cancer

A painless lump in the neck is found in nearly 75% of newly diagnosed nasopharyngeal cancer. A doctor should be seen if any of the following symptoms develop and persist: a painless lump in the neck, excessive nose discharge or blockage or bleeding, decreased hearing or ringing in the ears, or unusual face pain or numbness, double vision or headache. As cancer can spread to any organ or tissue in the body, in the late stages there may be symptoms from the lung, bone or liver.

DIAGNOSIS

Diagnostic Tests:

If nasopharyngeal cancer is suspected, a doctor will look for swelling or lumps in the neck. The doctor may examine the nasopharynx with a special angled mirror that is placed at the back of the throat or pass a flexible tube called a nasoscope (usually 5 - 6 mm in diameter) into one of the nostrils and to the back of the nose to look for lumps or ulcers. Small pieces of tissues may be removed during this examination to diagnose cancer. This is called biopsy.

If there is a neck lump, small pieces of the lump can be removed using a needle and syringe under local anaesthesia. The tissue is then examined under a mircoscope to look for cancer cells.

Once cancer is confirmed, further tests will be done to see if the cancer has spread from the nasopharynx to other parts of the body. The tests usually include a thorough physical examination, blood tests, chest x-rays and scans of the head and neck region. A bone scan and liver scan may also be ordered to see if the cancer is suspected to have spread to these areas.

TREATMENT OPTIONS

Treatment of Nasopharyngeal Cancer

Early nasopharyngeal cancer is treated by radiotherapy. A team led by a radiation oncologist, a doctor who specializes in giving radiotherapy, plan radiation therapy. Radiation is given to an area that covers the region around the nasopharynx and the neck and down to the collarbone. Temporary side effects include redness and peeling of the skin of the neck and cheek area, dryness of the mouth, mouth ulcers and loss of appetite.

Chemotherapy is sometimes used as part of the treatment. Chemotherapy uses drugs that kills cancers when it has spread to other parts of the body such as lungs, liver, and bones. The drugs are injected into the hand veins.

Chemotherapy may also be used in combination with radiotherapy to improve the efficiency of radiotherapy. Due to the location of the cancer, surgery is not commonly used. In some patients, surgery may be used to remove lumps in the neck that have persisted or returned after treatment with radiotherapy.

Surgery may also be considered when the cancer in the nasopharynx recurs despite radiotherapy and there is no spread of cancer elsewhere in the body.

Prognosis of Nasopharyngeal Cancer

Clinical examinations, x-rays and pathology reports all help the medical team decide what the progress of an individual case of Nasopharyngeal Cancer may be. Then, the appropriate course of treatment will be put into action. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with Nasopharyngeal Cancer is reasonable. Early disease limited to nasopharyngeal can be cured with radiation in large majority.

Prevention

  • Eat plenty of fresh fruit, green vegetables and other sources of vitamin C to lower your cancer risk.
  • Avoid taking excessive amounts of salted fish and other preserved foodstuff.
  • Avoid active and secondary tobacco smoke exposure. Screening can help to detect lung cancer.

Frequently Asked Questions :

I have several relatives with nasopharyngeal cancer. None of them smoke. Why did they get it?

Nasopharyngeal cancer is not directly associated with smoking. It may be a virus-related cancer and therefore found in members of a close community or family but is not contagious. Although not proven to be hereditary, nasopharynx cancer is known to be present in several members of one family.

I have a painless neck lump. It did not get better after antibiotics. What should I do next?

Painless neck lumps may be due to infection of the mouth and throat area or it may be a benign lump. It is best to seek medical attention in case it is cancerous. If there are no obvious reasons for the neck lump such as throat infection or tuberculosis, surgical removal of the lump and sending it for further testing may be necessary.