Cancer Information

We are delighted to be associated with Jeet Association for Support to Cancer Care (JASCAP), a NGO dedicated to providing patient information on cancer care. This is the fourth oncology centre of TATA for JASCAP, two in Mumbai, one in Kolkata and now in Jamshedpur. We sincerely hope that the association between JASCAP and Meherbai Tata Memorial Hospital empowers patients and their caregiver community immensely.

https://jascap.org/cancer-books-pdf/

What is Cancer?

Cancer is the name given to a large group of diseases, all of which have one thing in common: cells that are growing out of control. Normally, the cells that make up all of the parts of our bodies go through a predictable life cycle -- old cells die, and new cells arise to take their place. Occasionally, this process goes awry, and cells begin to multiply out of control. The end result is a mass of cells, called a tumor. A benign tumor is one that does not spread, or metastasize to other parts of the body. It is considered noncancerous. A malignant tumor, on the other hand, can spread throughout the body and is considered cancerous. When malignant cells break away from the primary tumor and settle into another part of the body, the resulting new tumor is called either a metastasis or a secondary tumor.

There are several major types of cancers: carcinomas form in the cells that cover the skin or line the mouth, throat, lungs and organs; sarcomas are found in the bones, muscles, fibrous tissues and some organs; leukemia are found in the blood, the bone marrow, and the spleen; and lymphomas are found in the lymphatic system.

Causes of Cancer

Cancer often takes many years to develop. The process typically begins with some disruption to the DNA of a cell, the genetic code that directs the life of the cell. There can be many reasons for disruptions, such as diet, tobacco, sun exposure, reproductive history or certain chemicals. Some cells will enter a precancerous phase, known as dysplasia. Some cells will progress further to the state of carcinoma in situ, in which the cancer cells are restricted to a microscopic site, surrounded by a thick covering and do not pose a great threat.

Eventually, unless the body's own immune system takes care of the wayward cells, a cancer will develop. It may take as long as 30 years for a tumor to go through the entire process and become large enough to produce symptoms.

Symptoms of Cancer

Since cancer can arise from such a wide variety of sites and develop with many differing patterns of spread, there are no clear-cut symptoms . Cancer is unlike many more specific diseases such as heart disease or arthritic disease. The precise nature of symptoms of cancer depends not only on primary site but specifically where the tumor is located in an organ, rate of development and also secondary spread is present or not.

Many primary tumors cause local swelling or lump if they arise at a visible or accessible part of the body, such as a skin, breast, testicle or oral cavity. A typical swelling due to a cancer is initially painless, though ulceration (skin breakdown) can occur, which may then become painful.

Treatment of Cancer

The aim of cancer treatment is to cure the patient and save life. The cases where complete cure is not possible, treatment aims to control the disease and to keep the patient normal and comfortable as long as possible. The treatment of each patient is designed to suit an individual and depends on the age of the patient, stage and type of disease. There may be only one treatment or combination of treatments. There are four main modalities of treatment : Surgery, Radiation therapy, Chemotherapy, hormonetherapy and Immunotherapy. Surgery and radiotherapy aim at eradicating the disease at the primary site (site of origin) of cancer whereas chemotherapy, hormonetherapy and immunotherapy deal with disease which may have spread outside the site of origin of cancer. Surgery is the most important part of the cancer treatment. Surgery attempts to remove cancer cells from the body by cutting away the tumor and any tissues surrounding it which may contain cancer cells. It is a simple, safe and effective method when cancer is small and confined to the site of origin. It is best suited for certain type of cancers such as, breast cancer, head and neck cancers, early cancers of the cervix and lung, many skin cancers, soft tissue cancers and gastrointestinal cancers. Radiotherapy has become the pre-eminent form of cancer treatment since beginning of this century and now it is used for fifty percent of patients. Improvements in radiotherapy equipment, technique and applications, have led to an increasing role both in local treatment and also in its use as a whole-body treatment , as part of bone marrow transplantation techniques for leukaemia and other malignant diseases.

Radiation is a special kind of energy carried by waves or a stream of particles originating from radioactive substances and delivered by special machines. These radioactive x-rays or gamma rays can penetrate the cell wall and damage the nucleus of the cell which prevents growth and division of cells. This also affects the normal cells but these cells recover more fully than cancer cells. Chemotherapy uses drugs which interfere with the growth and division of malignant cells. Once the drugs are administered, they circulate throughout the body. It is advantageous over surgery & radiation for treating cancer that is systemic (spread throughout the body). Chemotherapy is very useful in treating cancers like leukemia, lymphomas, testicular cancer. Chemotherapy can be given as the primary treatment, or following surgery or radiotherapy to prevent reappearance of cancer.

The side-effects of the chemotherapy include nausea, vomiting, hair loss, fever etc. which are temporary and completely reversible. Hormone therapy has limited use in cancer treatment since only a small minority of tumors are hormone sensitive e.g. breast and prostate cancer. This therapy provides systemic means of treatment, i.e. to the whole body, but without the side effects of chemotherapy. In summary, it is misconception that all cancers are incurable. Current methods of treatment are effective for many cancers. A large number of cancer patients are cured and more patients could be cured if their cancers were detected early and treated promptly.

Source: TMH, Mumbai

Bladder cancer

Of the three main types of bladder cancers, the most common is transitional cell carcinoma. Less common bladder cancers include squamous cell carcinomas and adenocarcinomas.

A patient's treatment and survival rate depend on how deeply the cancer has invaded the bladder, and if it has spread to surrounding or distant sites.

Symptoms

The most common symptom of bladder cancer is blood in the urine. This symptom is usually painless, and is not always visible to the naked eye. Often, the diagnosis of bladder cancer is delayed because bleeding is intermittent. Other symptoms include an increased frequency of urination, an increased urgency to urinate, feeling the need to urinate but not being able to, and painful urination.

If you have one or more of these symptoms, it does not mean that you have bladder cancer. However, it is important to see a doctor so that any illness can be diagnosed and treated as early as possible.

Diagnosis

Bladder cancer is most often diagnosed by examining cells in the urine under a microscope and by inspecting the bladder with a cystoscope -- a slender tube fitted with a lens and a light that is inserted into the bladder through the urethra.

If cancer is suspected, a tissue sample is removed during the cystoscopic procedure and examined under a microscope. If cancer is confirmed, computed topography (CT) may also be needed to determine the stage of the cancer -- whether the cancer is confined to the bladder or whether it has spread to other parts of the body, such as the lymph nodes, lungs, bones, or liver. Research is under way at Tata Memorial Centre to determine if magnetic resonance imaging (MRI) and positron emission tomography (PET) can more accurately diagnose and stage bladder cancer.

Treatment

Treatment for bladder cancer varies greatly depending on the stage of disease at the time of diagnosis.

Superficial Bladder Cancer

The majority of bladder cancers are transitional cell carcinomas (TCC) that are confined to the lining of the bladder. The standard treatment for superficial bladder cancer is minimally invasive surgery using a cystoscope to remove the tumor.

Invasive Bladder Cancer

Surgery to remove the bladder is the most common treatment for invasive bladder cancer -- cancer that has spread into or beyond the muscle layer of the bladder wall -- and provides the best opportunity for a long-term cure for most patients.

For patients whose tumors require surgery to remove the entire bladder, it is also necessary to remove the surrounding lymph nodes to help prevent cancer recurrence or metastasis. In women, this procedure also involves the removal of the lower portion of the ureters, the uterus, fallopian tubes, the ovaries, and sometimes part of the vaginal wall and the urethra. In men, the prostate gland, the lower portion of the ureters, and sometimes the urethra are removed. After removing the bladder, surgeons must create a new way for the body to store and eliminate urine. The historical approach, called an ileal conduit, required a patient to wear a bag on the outside of the body to collect urine. During this procedure, a conduit for the urine was created using a segment of the small intestine. It transferred urine directly from the kidneys and ureters, and required a stoma on the skin to funnel the urine into the collection bag.

For people whose urethra has been removed, an internal bladder is created and then attached directly to the abdominal wall. A stoma is attached to the internal bladder, and the patient inserts a catheter into the stoma to eliminate the stored urine. It takes about three to five minutes to empty the bladder this way.

Many patients with muscle-invasive bladder cancer are treated with chemotherapy before or after surgery, using M-VAC or other regimens that have fewer side effects, to help prevent the recurrence of cancer.

 

Breast Cancer

Breast cancer is the most common of all cancers and is the leading cause of cancer deaths in women worldwide, accounting for >1.6% of deaths and case fatality rates are highest in low-resource countries. A recent study of breast cancer risk in India revealed that 1 in 28 women develop breast cancer during her lifetime. This is higher in urban areas being 1 in 22 in a lifetime compared to rural areas where this risk is relatively much lower being 1 in 60 women developing breast cancer in their lifetime. In India the average age of the high risk group in India is 43-46 years unlike in the west where women aged 53-57 years are more prone to breast cancer.

Risk Factors
The risk factors influencing breast cancer risk are broadly classified into modifiable and non –modifiable factors. The non modifiable risk factors are age, gender, number of first degree relatives suffering from breast cancer, menstrual history, age at menarche and age at menopause. While the modifiable risk factors are BMI, age at first child birth, number of children, duration of breast feeding, alcohol, diet and number of unsuccessful pregnancies ( abortions).
Screening

Women with a higher than average risk of developing breast cancer may be offered screening and genetic testing for the condition. NHS Breast Screening Programme recommends that women between 50-70 years of age of should be screened once every three years. Screening is especially recommended for women with risk factors, a significant one being family history. Having a 1st-degree relative (mother, sister, and daughter) with breast cancer doubles or triples the risk of developing the cancer. About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes, BRCA1 or BRCA2. If relatives of such a woman also carry the gene, they have a 50 to 85% lifetime risk of developing breast cancer. Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and an improvement in survival rates. Approximately 20% of the cancers detected in a given year will be missed at the screening, but will become clinically evident in the period before the next screen (interval cancers).
Pathology

The various abnormalities of the breast include nipple discharge, inflammations, ANDI , benign disorders, phyllodes / sarcomas and carcinoma Most breast cancers are epithelial tumors that develop from cells lining ducts or lobules; less common are nonepithelial cancers of the supporting stroma (eg, angiosarcoma, primary stromal sarcomas, phyllodes tumor). Cancers are divided into carcinoma in situ and invasive cancer. Paget's disease of the nipple is a form of ductal carcinoma in situ that extends into the overlying skin of the nipple and areola, manifesting with an inflammatory skin lesion and may become invasive.

The pathological variations of breast cancer influence the prognosis. In situ cancers (DCIS/LCIS) are slow growing, indolent tumors. Autopsy studies have indicated that the incidence of DCIS in asymptomatic women ranges from .02% to 18.2% indicating that some DCIS do not become evident during a women’s lifetime. Invasive carcinoma is primarily adenocarcinoma. About 80% is the infiltrating ductal type; most of the remainder is infiltrating lobular. The pathological variants with a favorable prognosis are tubular, cribriform, mucinous and adenoid cystic variants, while intermediate prognosis is seen with medullary, secretory and invasive lobular cancers. The most unfavorable pathology is high grade metaplastic, micropalliary, signet ring cell morphology, inflammatory cancer.
Pathophysiology

Breast cancer invades locally and spreads initially through the regional lymph nodes, bloodstream, or both. Metastatic breast cancer may affect almost any organ in the body—most commonly, lungs, liver, bone, brain, and skin.

Symptoms & Signs

Most breast cancers present as a lump felt by the patient or during routine physical examination or mammography.

Less commonly, the presenting symptom is thickening in the breast. Paget's disease of the nipple presents with skin changes, including erythema, crusting, scaling, and discharge.

A few patients with breast cancer present with signs of metastatic disease (eg, pathologic fracture, pulmonary dysfunction).

During a physical examination a lump is felt distinctly different from the surrounding breast tissue. More advanced breast cancers are characterized by fixation of the lump to the chest wall or to overlying skin, by satellite nodules or ulcers in the skin. Matted or fixed axillary lymph nodes suggest tumor spread. Inflammatory breast cancer is characterized by diffuse inflammation and enlargement of the breast, often without a lump, and has a particularly aggressive course.
Diagnosis

The triple assessment includes: clinical examination, radiological investigation and pathological correlation.

Radiololgy

Mammogram, ultrasound
Diagnostic mammography is a standard procedure done as part of the triple test for diagnosing breast cancer. However the efficacy of diagnostic mammography is anecdotal.

Often, the lump is not even visible on the mammogram or a lump is visible on mammogram but the appearance may be indeterminate. If the lesion is clinically suspicious and is not a cyst by ultrasonography or aspiration, then a biopsy is indicated despite the mammographic results. In this case, the mammogram adds little to the diagnosis. Its main use is for screening the rest of the breast and the contralateral breast for unsuspected cancer.

The lump may have a classic appearance of a benign calcifying fibroadenoma, mixed radiographic density hamartoma, or fat lesion such as fat necrosis or a lipoma. The appearance of these lesions can be used to avoid a biopsy, so that in these cases, the diagnostic mammogram is very helpful.

The lump may have a classic appearance of breast cancer and biopsy is clearly indicated. In this case, the mammographic findings could prevent a delay in diagnosis by making it clear that a biopsy is needed.

Magnetic Resonance Imaging MRI is useful to locate a suspicious mammographic lesion that cannot be located by CBE or ultrasonography. Especially useful in young women with dense breast, women with implant in situ, previously operated breasts, recurrent lesions, wherein mammography may not be accurate.

Pathology

Needle Biopsy / FNAC

Confirmation of malignancy with cytology or histology is the minimum requirement for “indeterminate” or “high-risk” solid lesions. Fine-needle aspiration / Tru cut / core biopsy / surgical excision/ Incision biopsy / percutaneous breast biopsy for non-palpable disease are the various methods used to obtain tissue for pathological confirmation. If a woman is being treated with neoadjuvant therapy it is essential to perform a biopsy to obtain the ER/PR status of the tissue.
Staging

The TNM staging is traditionally used to stage breast cancer (link) Patients are clinically grouped into one of the following categories

* Operable Breast Cancer
* Large Operable Breast Cancer
* Locally Advanced Breast Cancer
* Metastatic Breast Cancer

Treatment

Evidence Based Guidlines

Breast cancer can be treated using a multimodality approach of surgery, chemotherapy, radiotherapy and targeted therapy. The treatment options vary as per the stage of the tumor. There are multiple ongoing clinical trials in breast cancer; TMH is involved in many of the same.
Information for Patients

Breast cancer is one of the commonest cancers in women in India. It is also one of the curable cancers if detected early. Any woman would dread getting cancer of the breast. Cancer subjects the family to unimaginable emotional stress. If you or someone you know has been diagnosed to have breast cancer it is important that you understand the disease, since ignorance breeds myths. We then have to fight not just the 'CANCER' but also the 'MYTHS'.

  • Breast Cancer Awareness
  • What After Diagnosis
  • Treatment plan
  • Post op instructions
  • Adjuvant therapy
  • Follow up
  • Coping with cancer

 

Cervical Cancer

Cervical cancer is cancer of the cervix -- the opening of the uterus, extending into the upper end of the vagina. Some 12,000 American women will be diagnosed with cervical cancer this year. Thanks to effective screening, which can detect cervical precancers and cancers early, most of them can be cured.

With the advent of widespread screening by a vaginal smear test developed by George Papanicolaou in the 1950s (commonly known as the "Pap smear"), the number of deaths from cervical cancer has fallen dramatically -- from more than 35,000 per year to about 4,000 per year today.

A Slow-Growing, Treatable Cancer

Cervical cancer usually grows slowly over many years. Before true cancer cells develop, the tissues of the cervix undergo changes -- called dysplasia, or precancers -- that a pathologist can detect in a Pap smear. These changes range from mild dysplasia or cervical intraepithelial neoplasia (CIN1) to moderate (CIN2) to high-grade lesions (CIN3). They can also resemble cancer cells without invasion, also known as carcinoma in situ.

If left untreated, these precancers have the propensity to invade and become cancerous. Once they spread beyond the borders of the cervix, they can invade tissues more deeply, into either the vagina or the uterus, and ultimately metastasize to other parts of the body.
Overview

There are two main types of cervical cancer:

  1. Squamous Cell Carcinoma
    The majority of cervical cancers -- 85 to 90 percent -- are squamous cell carcinomas.
  2. Adenocarcinoma
    The remaining 10 to 15 percent of cervical cancers are adenocarcinomas.

Cancers that have features of both cell types are known as mixed, or adenosquamous, carcinomas.

Risk Factors

The most significant risk factor for cervical cancer is infection with the human papillomavirus (HPV), which can be transmitted during sex.

Papillomaviruses have been known to cause cervical dysplasia, or precancers, for more than two decades. More recently, DNA from these viruses has been found to exist in virtually all cervical squamous cell carcinomas (the most common type of cervical cancer).

By avoiding the following known risk factors for HPV infection, women can reduce their likelihood of developing cervical cancer:

  •     Early age at first sexual intercourse (15 years or younger)
  •     Having a history of many sexual partners (more than seven)
  •     Smoking (which produces chemicals that can damage cervical cells, making them more vulnerable to infection and cancer)
  •     Infection with HIV (which reduces the body's ability to fight off HPV infection and early cancers)

Women without these risk factors rarely develop cervical cancer. Although all women can help protect themselves from disease by having their sexual partners use condoms, condoms do not provide complete protection from HPV infection because this virus (unlike HIV) can be spread by contact with any infected area of the body.

Symptoms

Cervical cancer, especially in its earliest stages, often causes no symptoms. That's why it's so important to see your doctor for regular screening with a Pap test.

When symptoms do occur, they may include the following:

* pain or bleeding during or after intercourse
* unusual discharge from the vagina
* blood spots or light bleeding other than a normal period

These symptoms can be caused by cervical cancer or by a number of serious conditions, and should be evaluated promptly by a medical professional.
Diagnosis

A Pap test is used to detect the possibility of a cervical cancer or dysplasia (precancer).

Biopsy

If a Pap test shows an abnormality, your doctor will perform a biopsy (by removing a sample of cervical tissue for microscopic examination). A gynecologist will often use a colposcope (a viewing tube attached to magnifying binoculars) to find the abnormal area and remove a tiny section of the surface of the cervix, which a pathologist will examine to see if it contains precancer or cancer cells. He or she may also perform a Schiller test, in which the cervix is coated with an iodine solution. Iodine causes the healthy cells to turn brown, while abnormal cells appear white or yellow.

Cone Biopsy

If the diagnosis isn't clear, a surgeon may remove a slightly larger, cone-shaped piece of tissue (called a cone biopsy). At Tata Memorial Centre, cone biopsies are often performed by loop excision, in which an electrical current is passed through a thin wire loop to remove the sample tissue. Loop excision takes only about 10 minutes under local anesthetic. The cone biopsy is also a treatment, and can completely remove many precancers and early cancers. More than 90 percent of cervical cancers can be halted with this technique without further treatment.

Cytoscopy & Other Imaging Tests

If your doctor suspects that the cancer may have spread beyond the cervix, you may have cytoscopy (examination of the bladder using a lighted tube), proctoscopy (examination of the rectum), a chest x-ray, or other imaging tests -- such as a computerized tomography scan (CT scan) of the abdomen and pelvis to check for metastatic disease, or magnetic resonance imaging scan (MRI scan) of the pelvis to check the extent of local disease.

Treatments

Options for treating cervical cancer depend chiefly on the stage of disease -- the size of the cancer, the depth of invasion, and whether the cancer has spread to other parts of the body. The primary forms of treatment are surgery and combined radiation therapy and chemotherapy.

Carcinoma In Situ

These cancers are preinvasive and can be treated conservatively, sparing the uterus. Options for treatment include

  • Laser surgery (in which a narrow beam of intense light is used to kill the cancerous cells)
  • Loop excision (in which an electrical current is passed through a thin wire loop to remove the cells)
  • Cone biopsy (to surgically remove a cone-shaped piece of tissue containing the cancer)

These treatments are almost always effective in removing precancers and stopping them from developing into true cancers.

Early Cervical Cancer (Stages I-IIA)

For early cervical cancers that are confined to the cervix, surgical options may include hysterectomy (removal of the uterus), sometimes along with the tissue next to the uterus. Lymph nodes from the pelvis are also removed and examined for cancer cells. If the cancer is associated with "high-risk" features -- such as involvement of the pelvic lymph nodes, invasion of the lymph channels or blood vessels of the cervix, or involvement of the tissue along the uterus -- doctors recommend chemotherapy combined with radiation therapy.

Advanced Cervical Cancer (Stages IIB-IVA)

If cervical cancer has spread beyond the cervix and into the surrounding pelvic tissues, surgery alone is usually not an effective cure. Patients with this degree of invasive cancer have traditionally also been treated with radiation therapy (the use of x-rays or other high-energy waves to kill cancer cells and shrink tumors), either alone or in addition to surgery.

In recent years, however, there has been a major shift in the treatment of advanced cervical cancer. Based on the results of large clinical trials, the standard of care for regionally advanced cervical cancer is now chemotherapy combined with radiation therapy. The radiation therapy may be delivered externally and/or internally (by placing an implant to deliver radioactive material immediately around the cervix).

Stage IVB & Recurrent Cervical Cancer

For women whose cancer spreads beyond the pelvis (into the lungs or liver, for example) or who have recurrent disease, treatment is aimed at reducing cancer-related symptoms in order to improve a patient's quality of life, and hopefully to prolong her survival. Chemotherapy is the primary modality of treatment for these patients, and several drugs are available for treating these women.

For women whose disease recurs in the pelvis, extensive surgery may be the only curative option and requires a highly experienced multidisciplinary team.

 

Colorectal Cancer

Prevention and early detection are key factors in controlling and curing colorectal cancer. Indeed, colorectal cancer is the second most preventable cancer, after lung cancer. When the cancer is found early, initial treatment can often lead to an excellent outcome. Colorectal cancer is cancer that occurs in the large intestine and rectum. The colon is a muscular tube that is about five feet long. It absorbs water and nutrients from food. The rectum, the lower six inches of the digestive tract, serves as a holding place for stool, which then passes out of the body through the anus. Although many people think of colorectal cancer as a disease that primarily affects men, it is slightly more common in women. Today, the average person has about a 1 in 20 chance of developing colorectal cancer during his or her life.

How Colorectal Cancer Develops?

The colon is divided into four sections: the ascending colon, transverse colon, descending colon, and sigmoid colon. Most colorectal cancers arise in the sigmoid colon -- the portion just above the rectum. They usually start in the innermost layer and can grow through some or all of the several tissue layers that make up the colon and rectum. The extent to which a cancer penetrates the various tissue layers determines the stage of the disease. Most colorectal cancers grow slowly over a period of several years, often beginning as small benign growths called polyps. Removing these polyps early, before they become malignant, is an effective means of preventing colorectal cancer.
Symptoms

Colorectal cancer sometimes arises without any symptoms. For this rehis year, about 148,000 people in the United States will be diagnosed with colorectal cancerason, screening tests (such as colonoscopy and a test for blood in the stool) are recommended to detect the cancer early, when it is more curable.

Symptoms

When symptoms do occur, however, they may include the following:

Rectal bleeding or blood in the stool a change in bowel habits (such as diarrhea, constipation, and narrowing of the stool) that lasts for more than a few days abdominal pain a continuous feeling that you need to have a bowel movement, which does not resolve after passing stool weakness

Some of these symptoms may be caused by other conditions. But you should see your doctor if they persist. Any incidence of rectal bleeding or blood in the stool should be brought to your doctor's attention.

Screening And Diagnosis

The best way to cure colorectal cancer is to prevent it from occurring in the first place. A regular program of screening examinations is the best way to ensure an early diagnosis, and an early diagnosis offers the best chance for a cure.

Screening & Diagnostic Tests

Colorectal cancer screening and diagnosis may involve one or more of a number of procedures:

Colonoscopy
This examination allows the doctor to inspect the rectum and colon, using a thin tube that has a light on the end. It is inserted into the rectum while the patient lies on his or her side. Patients often receive a mild sedative during this procedure to ensure their comfort. Any polyps or other growths that are found during these examinations are usually removed at the time and sent to a laboratory for examination.
A ten-year study by Tata Memorial Centre investigators showed that colonoscopy was more effective than another screening technique called double-contrast barium enema for detecting precancerous colon polyps. The findings of this study were the first to show that the various surveillance tools used to follow patients who have had colon polyps removed are not equally reliable. Moreover, unlike barium enema, colonoscopy allows the doctor to remove any polyps at the time of the examination.

Fecal Occult Blood Test
Also known as a stool blood test, this laboratory test looks for blood in the stool. The patient is asked to follow a special diet and then bring in stool specimens (usually applied to small, folded cards) from three successive days.

Flexible Sigmoidoscopy
This examination is similar to the colonoscopy exam, but it uses a shorter tube to inspect the lower colon.

Virtual Colonoscopy

Virtual colonoscopy is a new technique that uses CT scans to create a 3-D image that can be used to evaluate the bowel. At this time, it is still a research tool and is not generally available. It is also important to note that, while this is a promising technique, it does not allow for a biopsy or polyp removal at the same time an abnormality is found.

For more information about diagnostic tests, see Staging.

Screening Guidelines

If you do not have an increased risk of colorectal cancer because of your personal or family medical history, we recommend the following screening tests, beginning at age 50:

  • Colonoscopy every 10 years
  • A yearly test for blood in the stool, preferably combined with flexible sigmoidoscopy every five years

If you have an increased risk of colorectal cancer because of your personal or family medical history, you should have a colonoscopy every 5 years beginning at age 40, or younger if hereditary non-polyposis colorectal cancer (HNPCC) is suspected. For first-degree, direct relatives of patients with colorectal cancer that has presented before age 50, screening should begin 10 to 20 years before the age of the diagnosed patient. For example, if your father is diagnosed with colorectal cancer at age 48, then you should begin your own colorectal cancer screening between ages 28 and 38.
Staging

If tests show that you have colorectal cancer, additional examinations may be performed to determine its extent -- a process called staging. Knowing how far your cancer has progressed is important when deciding what regimen of treatment might be most appropriate for you. The following tests are routinely used to stage colorectal cancer:

  • Computed tomography (CT) and magnetic resonance imaging (MRI) scans, which may be used to see if the cancer has spread to other organs, such as the liver and lungs
  • Chest x-ray, which may be performed to see if the cancer has spread to the lungs
  • Blood tests for CEA, a protein that acts as a marker for colorectal cancer

Depending on your specific clinical situation, these additional tests may be ordered:

  • Positron-emission tomography (PET) scanning, which may be conducted to find other places where cancer may be lurking
  • Angiography, which may be done to find blood vessels next to cancer that has spread to the liver, allowing doctors to plan surgery to minimize blood loss
  • Endorectal ultrasound probe, which uses sound waves to produce an image of the tumor; it may be placed in the rectum to see how far a cancer has invaded the rectal wall. This procedure is used for staging rectal cancer only.

Treatment
The choice of treatment for colorectal cancer depends on the stage of the disease -- that is, how large the tumor has grown, how deeply it has invaded the layers of the colon or rectum, and whether it has spread to other organs (most commonly the liver), lymph nodes, or other parts of the body.

Treatment options include surgery, radiation therapy, chemotherapy, and combinations of these approaches.

 

Gastric (Stomach) Cancer

Your stomach is a J-shaped organ in the upper abdomen where digestion begins before food is passed to your intestines. Cancer can arise in any part of the stomach, and is believed to develop slowly over many years.

Stomach cancer -- also referred to as gastric cancer -- is usually preceded by precancerous changes in the stomach lining, although these changes rarely produce symptoms. Because stomach cancer often does not cause symptoms until it is quite advanced, it is not often detected in its earliest stages.

Most stomach cancers (90 to 95 percent) are classified as adenocarcinomas. Other types of stomach cancer include squamous cell carcinoma, lymphoma, stromal tumors (cancer of the muscle or connective tissue of the stomach wall), and carcinoid tumors (cancer of the hormone-producing cells of the stomach).

Risk Factors

The following factors increase the risk of stomach cancer:

  • Infection with the Helicobacter pylori bacterium, which may lead to chronic inflammation of the inner layer of the stomach and possibly precancerous changes; recent research has shown that antibiotic treatment may reduce the risk of stomach cancer -- particularly stomach lymphoma -- in people infected with this bacterium
  • A diet high in consumption of smoked and salted foods, such as smoked fish and meat and pickled vegetables; conversely, eating a diet high in fruits and vegetables (particularly those high in beta-carotene and vitamin C can decrease stomach-cancer risk
  • High consumption of red meat; studies show that eating red meat more than 13 times per week can double the risk of stomach cancer
  • Smoking
  • Alcohol abuse
  • Previous stomach surgery, such as removal of stomach tissue in patients with ulcers
  • Pernicious anemia, a severe inability to produce red blood cells, due to a deficiency of vitamin B12
  • Menetrier's disease, a very rare condition associated with large folds in the stomach and low production of stomach acids
  • Blood type A (for unknown reasons)
  • Family cancer syndromes, such as Lynch syndrome and familial adenomatous polyposis, which increase colorectal-cancer risk and slightly increase stomach-cancer risk
  • Family history of stomach cancer
  • Stomach polyps (small benign growths that sometimes develop into stomach cancers).

Symptoms

When symptoms of stomach cancer arise, they may include:

  • Indigestion and stomach discomfort
  • A bloated feeling after eating
  • Mild nausea
  • Loss of appetite
  • Heartburn

In the more advanced stages of stomach cancer, a patient may experience the following symptoms:

* blood in the stool
* vomiting
* unexplained weight loss
* stomach pain

These symptoms may also result from more benign illnesses, such as simple indigestion or a stomach virus. However, if you have these symptoms over a long period of time, you should see your doctor.
Diagnosis

If your doctor suspects that you may have stomach cancer, you may have a barium x-ray of your upper gastrointestinal system. For this test, you will be asked to drink a liquid containing barium, which makes your stomach easier to see on an x-ray. This test can be performed in a doctor's office or a hospital's radiology department.

The doctor may also look inside your stomach using a gastroscope, a thin, lighted tube that is inserted into your mouth and guided into your stomach (also called upper endoscopy). A camera at the end of the tube enables your doctor to see inside your stomach. Your doctor may take small samples of tissue to examine for cancer cells. (You will receive a spray of anesthetic into your throat or other medication to ensure that you are comfortable during this examination.)

A third, newer technique to diagnose stomach cancer is called endoscopic ultrasound. Similar to gastroscopy, endoscopic ultrasound relies on a thin tube inserted into the mouth and down into the stomach. At the tip of the tube is a small ultrasound probe that bounces sound waves off the stomach walls. This test is useful for estimating how far cancer has spread into the wall of the stomach, to nearby organs, and to nearby lymph nodes -- a process called staging.

Another staging technique is called laparoscopy. This procedure involves minor surgery using a small tube with a camera at the end to look inside your abdomen. Doctors can look at the outside wall of your stomach, examine the lymph nodes, and evaluate the surfaces of other abdominal organs to determine if the cancer has spread to those areas.

In addition to these diagnostic tests, your doctor will take your medical history into account, perform a physical examination, and order laboratory studies such as blood tests.

Treatment

The choice of treatment for stomach cancer depends on the stage of the disease -- that is, how large the tumor has grown, how deeply it has invaded the layers of the stomach, and whether it has spread to nearby organs, lymph nodes, or other parts of the body.

Recent investigations suggest that a three-pronged attack on stomach cancer -- utilizing surgery to remove most of the tumor and chemotherapy and radiation therapy to control cancer spread -- may improve the survival of patients with stomach cancer. This combination approach is expected to become the standard of care for patients with this disease.

Surgery

Surgery is the most common form of treatment for stomach cancer. If the results of staging indicate that surgery is likely to help you, your doctor may perform one of these operations to remove the cancer:

  • Subtotal gastrectomy : removal of the part of the stomach that contains the cancer and parts of other tissues or organs near the tumor (such as the small intestine or esophagus, depending on the location of the tumor)
  • Total gastrectomy : removal of the entire stomach and parts of the esophagus, small intestine, and other tissue near the tumor; in this case the esophagus may be connected to the small intestine so that you can continue to eat and swallow.
  • During the surgery, the surgeon will also remove nearby lymph nodes to examine them for cancer cells. Sometimes the spleen (an organ in the upper abdomen that filters blood and removes old blood cells) and part of the pancreas are also removed.

Chemotherapy

Chemotherapy -- treatment with cancer-killing drugs -- is another option for treating stomach cancer. It can be given to patients whose cancers have invaded the layers of the stomach wall, nearby lymph nodes, and nearby organs. Chemotherapy may be given before surgery (so-called neoadjuvant therapy) -- to shrink the tumor first -- or after surgery (adjuvant therapy), to kill any remaining cancer cells. These approaches are being evaluated in clinical trials.

When given alone or with radiation therapy, chemotherapy is also useful in some patients to relieve stomach-cancer symptoms or to delay cancer recurrence and extend a patient's life, especially in patients whose cancers cannot be completely removed through surgery. 5-fluorouracil and cisplatin are the drugs most commonly used to treat stomach cancer; other drugs (including paclitaxel, docetaxel, and irinotecan) and new combinations of conventional drugs are currently under investigation. Some are given intravenously (through a vein), while others are given intraperitoneally (delivered directly into the abdominal cavity).

Radiation Therapy

Radiation therapy is most commonly used in combination with chemotherapy for the treatment of gastric cancer. New studies reveal that for many patients with gastric cancer, the addition of radiation therapy plus chemotherapy after surgery improves survival compared to surgery alone.

 

Head & Neck Cancer

The term "head and neck cancer" encompasses a wide range of tumors that occur in several areas of the head and neck region, including the nasal passages, sinuses, mouth, throat, larynx (voice box), swallowing passages, salivary glands, and the thyroid gland. Skin cancers that develop on the scalp, face, or neck may also be considered head and neck cancers.

Each year, approximately 60,000 Americans are diagnosed with a head or neck cancer (not including skin cancers that occur in the region). Most of these cancers are preventable. Head and neck cancer can develop in anyone, but people who use tobacco (including cigarettes, cigars, pipes, and smokeless tobacco) or drink alcohol excessively are much more likely than others to develop the disease.

Types of Head & Neck Cancer

There are many different types of head and neck cancer. Several of them are described below. Most head and neck cancers are termed squamous cell carcinomas, because they begin in the flat squamous cells that form a thin outer layer on many parts of the body. When a cancer is limited to that layer of cells, it may be called a carcinoma in situ. When it has grown beyond that layer and moved into deeper tissues it may be termed an invasive squamous cell carcinoma. Cancers that arise in glandular cells, such as those in the salivary glands, are called adenocarcinomas.

Oral cancer is cancer that arises in the mouth, or oral cavity. The oral cavity includes the lips, the gums and the area behind the wisdom teeth, the inside of the lips and cheeks, the floor and roof (hard palate) of the mouth, and the front two-thirds of the tongue.

Laryngeal cancer begins in the larynx, an organ also known as the voice box. The larynx sits at the top of the trachea, the tract that leads to the lungs. Air passes through the larynx on the way to the lungs. The vocal cords, two bands of muscle, are found within the larynx and are used for speech. The larynx also prevents food from entering the lungs. The larynx is visible on most men's throats as the Adam's apple.

Nasal cavity and paranasal sinus cancers are found in the tissues that line these hollow structures. The paranasal sinuses are hollow areas in the bones of the face near the nose that produce mucus. The nasal cavity is found just behind the nose and is used to pass air to the throat.

Nasopharyngeal cancer is found in the nasopharynx, the uppermost portion of the throat (pharynx). It begins just behind the nose and extends to the oropharynx, the portion of the throat found just behind the mouth. It also includes two openings that lead to the ears. (The entire throat is called the pharynx, and is made up of the nasopharynx, the oropharynx just below that, and the hypopharynx, the lower region that meets the esophagus.)

Oropharyngeal cancer is found in the section of the throat (oropharynx) located just beyond the mouth. The region also includes the base of the tongue, the soft palate (the soft area just beyond the roof of the mouth), and the area around the tonsils.

Hypopharyngeal cancer is found in the hypopharynx, the uppermost portion of the esophagus (the tube through which food travels to the stomach). The hypopharynx surrounds the larynx.

Salivary gland cancer is found in the salivary glands, the structures that produce saliva to keep the mouth from drying out and aid in the digestion of food. Salivary glands may be found under the jaw, in front of the ears, underneath the tongue, and in other areas of the upper aerodigestive passages including the nose, sinus, mouth, and throat.

Thyroid cancer develops in the thyroid gland, a small butterfly-shaped structure that wraps around the front of windpipe in the lower part of the neck. The thyroid gland is the source of important hormones that help regulate metabolism, blood pressure, heart rate, temperature and other functions.

Symptoms

Below are some of the symptoms and warning signs of head and neck cancer. Many of these symptoms can be caused by other, non-cancerous conditions as well. See your doctor if you notice any of these problems.

  • A sore in the mouth that won't heal (the most common symptom) or that bleeds easily
  • A red or white patch in the mouth that doesn't go away
  • Frequent nosebleeds, ongoing nasal congestion, or chronic sinus infections that do not respond to treatment
  • Persistent sore throat
  • Persistent hoarseness or a change in the voice
  • Pain in the neck, throat, or ears that won't go away
  • Blood in the sputum
  • Difficulty chewing, swallowing, or moving jaws or tongue
  • Numbness in the tongue or other areas
  • Loosening of teeth
  • Dentures that no longer fit
  • A lump or swelling in the neck
  • Ahanges in a mole or discoloration, or a sore on the skin that is crusting, ulcerated, or fails to heal (these are Also signs of skin cancer).

Diagnosis

Our doctors perform any of several types of tests that can help to make a definitive diagnosis of a head and neck cancer and to determine the stage of the cancer, or how far it has progressed.

Physical Examination and History

First, the doctor or nurse will take a complete medical history, noting all symptoms and risk factors. Then you will have a thorough examination of the head and neck area, during which the doctor will feel for abnormalities and looking at the inside of your mouth and throat.

Endoscopy

The doctor may use mirrors and lights to examine hard-to-see areas and may also use a flexible, lighted tube to examine areas that are less accessible. The tube may be inserted through the nose or mouth; an anesthetic spray may be used to make the examination more comfortable. This examination is called a nasopharyngoscopy, pharyngoscopy, or laryngoscopy, depending on which area is examined. Occasionally, this type of examination will be done while the patient is under general anesthesia so a very thorough inspection can be done; this is called a panendoscopy.

Imaging Tests

The doctor may also suggest several other tests, including imaging procedures such as a CT or computed tomographic scan (a special type of x-ray), an MRI or magnetic resonance image scan (which uses magnetic waves to produce pictures), or an ultrasound exam (which uses sounds waves to produce images). At Tata Memorial Centre, doctors also use PET (positron emission tomography) scans to help diagnose head and neck cancers. Currently, we are investigating whether PET scans will improve the ability to detect the spread of cancer to lymph nodes in the neck and other areas of the body.

Other possible tests include a panorex (a special x-ray of the jaws), a barium swallow, dental x-rays, chest x-rays, and a radionuclide bone scan.

Biopsy

If a suspicious area is noted, the doctor may do a biopsy: he or she will remove a small piece of tissue with either a scalpel or a needle, and send it to a laboratory for examination under a microscope. Biopsies are often done when the patient is under general anesthesia.

Treatment

Many cancers of the head and neck can be cured, especially if they are found early. Treatment varies according to the type, severity, and location of the disease. It may include surgery (the primary treatment method), radiation therapy, or chemotherapy. Increasingly, Tata Memorial Centre's physicians are combining treatment modalities to maximize chances of curing the cancer.

Although cure of the cancer is the primary goal in treatment, preserving a patient's appearance and ability to function, and thus the quality of life, also are very important goals and are considered an integral part of treatment. Today, advances in surgical techniques, reconstruction, and nonsurgical treatment methods -- combined with a comprehensive team approach, which brings the expertise of numerous specialists to each patient's care -- have made it possible to attain those quality of life goals in nearly every patient receiving treatment.

Surgery

Surgery is the mainstay of treatment for most cancers of the head and neck. Loss of speech was once common after head and neck surgery, because of damage to the larynx (voice box). Continual advances in surgical techniques, however, allow more patients to preserve normal functioning. Surgeons have perfected techniques, for example, that remove only part of the larynx instead of the entire organ. Indeed, larynx-preserving surgery is possible in more than half of the cases that once would have required that organ to be completely removed. Other advances now allow doctors to spare the eye when a tumor is crowding that area.

Some patients may need a surgical examination of the lymph nodes in the neck (called a neck dissection) to see if any cancer cells have spread beyond the site of origin; today, new techniques allow surgeons to remove these lymph nodes while sparing nerves that are important for shoulder function. Complex operations for tumors at the base of the skull -- once considered a very difficult prospect -- are now routinely performed. The skull base surgery team at Tata Memorial Centre is recognized as a world leader in this specialty.

When surgery is extensive, immediate reconstruction of the area is often possible. For example, in cases where the jaw bone must be removed, a surgeon can fashion a new jaw using bone from the patient's own leg. Blood vessels are moved along with the leg bone and are attached to blood vessels in the neck, creating a blood supply for the new jaw. Tata Memorial Centre surgeons developed this pioneering technique some 15 years ago. Similarly, skin and muscle from a patient's back or abdomen can now be used to replace part of the scalp. Dental implants can be used to replace teeth.

Radiation Therapy

Radiation therapy may involve external beam treatment or brachytherapy, a technique in which tiny radioactive seeds are implanted directly in a tumor. In some cases, both approaches are used. A three-dimensional method of delivering external beam radiation, known as intensity modulated radiation therapy, or IMRT, is used at Tata Memorial Centre for very precise delivery of radiation therapy to tumors. For example, this technique allows the radiation oncologist to "mold" the dose of radiation to encompass the tumor and spare the spinal cord, an approach that was impossible not long ago. IMRT helps to avoid damage to healthy tissues (thus reducing side effects) and makes possible the use of higher, more effective doses of radiation, as well as additional radiation to the area in some cases. Radiation therapy is often given in conjunction with surgical treatment, but studies are showing that in some cases, radiation therapy -- sometimes combined with chemotherapy -- is just as effective as surgery. These new approaches can often preserve the ability to speak and swallow normally, even in patients with advanced disease.

Chemotherapy

The use of chemotherapy in head and neck cancer is also expanding, especially in cases that previously would have been considered untreatable. Chemotherapy is often used to enhance the response of cancer cells to radiation therapy, and often makes it possible to preserve organs, such as the larynx, that once would have been removed. For patients with advanced disease, too, chemotherapy is helping to increase longevity; this is especially true in patients who have cancer of the nasopharynx or other areas that are not easily treated surgically. Chemotherapy drugs used include cisplatin, fluorouracil, methotrexate, carboplatin, and paclitaxel.

Investigational Approaches to Chemotherapy

Because head and neck cancers vary widely in their response to chemotherapy, Tata Memorial Centre researchers are looking at new tools to determine whether a particular cancer will be sensitive to treatment. One such experimental tool, the histoculture drug response assay, might one day permit rapid testing of cancer cells' response to commonly used drugs before treatment.

Tata Memorial Centre's clinical research protocols in head and neck cancers -- ranging from new approaches to preventing pre-cancers from becoming malignant to new treatments for advanced and recurrent cancers -- are sometimes offered to eligible patients through the clinical trial process. For up-to-date details about current clinical trials at Tata Memorial Centre, please visit our clinical trial database.

 

Leukemia

Leukemia is cancer that originates in the bone marrow, the soft, spongy inner portion of certain bones, and in which the malignant cells are white blood cells (leukocytes).

Leukemia develops when a leukocyte undergoes a transformation into a malignant cell -- one capable of uncontrolled growth. Leukemia cells begin to multiply in the marrow, and as they do so they crowd out the normal blood cells -- those that carry oxygen to the body's tissues, fight infections, and help wounds heal by clotting the blood. Leukemia can also spread from the marrow to other parts of the body, including the lymph nodes, brain, liver, and spleen.

Leukemia is ten times more common among adults than among children. Leukemias are evenly split between the acute and chronic forms, but among children one form -- acute lymphocytic leukemia -- accounts for about two-thirds of cases. Acute myeloid leukemia and chronic lymphocytic leukemia are the most common types in adults.

Blood cell development begins in the marrow with the formation of stem cells. These primitive cells are capable of developing into any kind of blood cell. The first step in this evolution, or differentiation, is into one of two slightly more mature types of stem cells: lymphocytic progenitor cells and myeloid progenitor cells. These cells then undergo further specialization. Lymphocytic stem cells mature into either T cells, B cells, or natural killer cells. Myeloid stem cells mature into erythrocytes (red blood cells); platelets (which clot the blood); monocytes (a type of white blood cell); or granulocytes (a group of white blood cells that includes neutrophils, basophils, and eosinophils). Each of these types of cell has a very specific job in the functioning of the body.

A malignant transformation can happen at any stage of blood cell development. The leukemia cells that result carry many characteristics of the cell from which they began. Most leukemias fall into one of two general groups: myeloid leukemia and lymphocytic leukemia. Physicians also classify leukemias according to whether they are acute or chronic. In acute leukemias, the malignant cells, or blasts, are immature cells that are incapable of performing their immune system functions. The onset of acute leukemias is rapid, and, in most cases, fatal unless the disease is treated quickly. Chronic leukemias develop in more mature cells, which can perform some of their duties but not well. These abnormal cells also increase at a slower rate, so the disease develops more slowly than in acute leukemia, and in many cases is more difficult to cure.

 

Lung Cancer

More than 90,000 men and 79,000 women are diagnosed each year with cancer of the lungs and bronchi (the air tubes leading to the lungs). Among men, the incidence of lung cancer has been declining, but it continues to increase among women. The number of lung cancer deaths among women surpasses those from breast cancer.

Recent studies indicate that female smokers may be more likely to develop lung cancer than male smokers.

Types of Lung Cancer

There are two major types of primary lung cancer: non-small cell and small cell. Each affects different types of cells in the lung and grow and spread in different ways, so doctors treat them differently. A diagnosis will include not only the type of lung cancer but the stage, which describes the extent and spread of the disease at diagnosis.

Non-Small Cell Lung Cancer

Non-small cell lung cancer, the most common type of lung cancer, is usually associated with a history of smoking. The three main types of non-small cell lung cancer are named for the type of cell found in the tumor: squamous cell carcinoma (also called epidermoid carcinoma); adenocarcinoma; and large cell carcinoma. Non-small cell lung cancer is described using four stages: in stage I, the cancer is confined to the lung; in stages II and III, the cancer is confined to the chest; and in stage IV, the cancer has spread from the chest.

Small Cell Lung Cancer

Small cell lung cancer (sometimes called oat cell lung cancer) accounts for approximately 20 percent of all lung cancer cases and is also associated with a history of smoking. The extent of the disease is described using a two-stage system. A case can either be limited, meaning the cancer is confined to a portion of the chest where it originated, or extensive, meaning the cancer has spread throughout or from the chest.

Mesothelioma, a rare cancer of the chest and abdominal lining, primarily affects persons who have had occupational exposure to asbestos particles.

Tumors found in the lungs sometimes originate from cancers elsewhere in the body. These tumors are called lung metastases.

Risk & Prevention

Smoking tobacco in any form is the major risk factor for lung cancer. Nonsmokers who breathe the smoke of others, often called secondhand smoke, are also at increased risk for lung cancer. Stopping exposure to tobacco smoke at any age lowers the risk of lung cancer.

Risk factors for lung cancer besides smoking include the following:

Radon
An odourless radioactive gas produced naturally in rocks and soil, radon is found in homes and mines in some areas. Exposure to high indoor radon levels can cause damage to the lungs that may lead to cancer.

Asbestos
If inhaled, asbestos particles can cause lung damage that may lead to lung cancer and mesothelioma (a rare cancer of the chest and abdominal lining).

Diagnosis
Lung cancer is difficult to detect early because symptoms usually do not appear until the disease is advanced. Symptoms depend on the location of the tumor and can include persistent cough, hoarseness or wheezing, shortness of breath, sputum streaked with blood, recurring bronchitis or pneumonia, weight loss and loss of appetite, and chest pain.

Physicians use several techniques to diagnose lung cancer, including the following:

  • Imaging Tests
  • Chest x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) help locate abnormal areas in the lung.
  • Low-Dose Helical CT

A technique called low-dose helical (or spiral) CT may offer a novel approach for diagnosing lung cancer by exposing the patient to less radiation than a conventional chest CT scan while allowing the doctor to see areas of the chest normally obscured in a standard x-ray.

Bronchoscopy & Biopsies

A sputum sample can be analyzed for the presence of cancerous cells. Doctors may perform a bronchoscopy, which allows them to examine the bronchial passages using an instrument called a bronchoscope. This is a small tube that is inserted through the nose or mouth, down the throat and into the bronchi. During the procedure physicians may remove some tissue for analysis.

A modified form of bronchoscopy called autofluorescence bronchoscopy, which can detect early invasive cancers not seen with standard x-rays or white-light bronchoscopy, is being used to detect very early lung cancer.

To examine areas of the lungs that are not accessible during a bronchoscopy, physicians may perform a needle biopsy ("fine needle aspiration" or FNA) to remove a small sample of tissue for analysis.

Smoking Cessation
Not everyone who gets lung cancer has a history of smoking. If you do smoke, however, you can reduce your risk for lung cancer -- and the risk of those around you -- by stopping now.

Treatment
Depending on the type and stage of the disease, lung cancer can be treated with surgery, chemotherapy, radiation therapy, or a combination of these treatments.

Surgery
For non-small cell lung cancers that have not spread beyond the lung, surgery is most often used. Over the past several years, surgical techniques for treating lung cancer have improved greatly.

There are three surgical procedures commonly used to treat lung cancer:

  • Wedge resection, or segmentectomy (in which a small section of the lung is removed)
  • Lobectomy (in which an entire section is removed)
  • Pneumonectomy (which involves the removal of an entire lung)

Minimally Invasive Surgery

Where appropriate, we offer minimally invasive surgical procedures, including video-assisted thoracic surgery (VATS), or thoracoscopy. VATS allows the surgeon to operate with roboting assistance by inserting an illuminated tube through a small incision into the lung through the ribs. Because the incisions are much smaller than with an open operation, post-operative healing time and pain are reduced.

Chemotherapy

For patients whose tumors are somewhat more advanced, a program of chemotherapy before surgery increases the cure rate. In some cases, the cancer is completely eliminated with chemotherapy before the patient has even had surgery.

Even if the surgeon removes the entire tumor that can be seen, adjuvant chemotherapy may be offered to kill cancer cells that may still be present in nearby tissues or elsewhere in the body. For small cell lung cancer in particular, chemotherapy, often combined with radiation therapy, is now the most common treatment.

Radiation Therapy

When surgery is not the best option, our radiation therapy system permits the delivery of the highest possible radiation dose targeted precisely to the tumor. This method spares normal tissues and lessens damage to other organs in the chest. Radiation therapy is also sometimes used to relieve pain and bleeding and alleviate problems with swallowing.

Both 3-D conformal radiation therapy and intensity modulated radiation therapy (IMRT) allow doctors to change the shape and intensity of radiation beams so they are focused more effectively on cancer cells and away from the surrounding tissue and organs.

 

Skin Cancer

Sunlight and Skin Cancer

Ultraviolet (UV) radiation is the single most important cause of skin cancer, especially when the overexposure resulted in sunburn and blistering. Other, less common causes of skin cancer include repeated exposure to x-rays and exposure to coal tar, arsenic, and other industrial compounds.

Sunlight provides much that is beneficial and even necessary to life and good health. Tanning and burning, however, are not among those benefits -- there is no such thing as a "healthy tan."

Over the past decade, researchers have discovered that the tanning response begins only after DNA in skin cells has been damaged by exposure to sunlight. Although the exact wavelengths and timing of the solar radiation associated with different types of skin cancer are under investigation, the basic preventive lesson remains the same: protect your skin from the sun.

Fortunately there are ways to prevent most non-melanoma skin cancers and to detect them early when they do arise. When treated early, the vast majority of these cancers are curable.

 

What is radiation therapy?
With a history of nearly one hundred years, Radiation Oncology has made remarkable progress to occupy a very important place in the therapeutic armamentarium against cancer. Starting from radium and ordinary x-ray machines, the specialty has made tremendous strides with integration of information technology in radiation planning and delivery.

Radiation oncology uses photon beams (x-rays: artificially produced photons, gamma rays: photons emitted by radioactive atoms) and particulate radiation (electron beams, heavy particle radiation) for treatment of cancer. The basic principle of radiotherapy is that high-energy radiation has the capability of killing cells: both normal cells and cancer cells. The selectivity is achieved by delivering radiation to a target area containing the entire gross and microscopic tumor and minimizing the amount of normal tissue irradiated.

What is the role of radiation therapy in cancer treatment?
Radiation alone can cure more than 90% of early cancers of head & neck area, cancers of uterine cervix, and non-melanoma skin cancers. Concomitant radiation therapy and chemotherapy provides high cure rates in a large variety of cancers such as head & neck cancers, cancers of esophagus, cancer of uterine cervix, anal cancers, etc. In addition, post-operative adjuvant radiation therapy is a very important component of treatment for head & neck cancer, breast cancers, sarcomas, pelvic cancers, etc. In many situations, radiation therapy is administered before surgery for downstaging of tumours to improve the surgical results. For cases that cannot be cured, palliative radiation therapy has a very important role. Palliative radiotherapy can be used for relief of various symptoms such as pain, bleeding, obstruction, etc.

How is radiation therapy administered?
Radiation can be given by two different approaches: teletherapy (external beam radiotherapy) or Brachytherapy (internal radiotherapy).

External Beam Radiation Therapy
External beam radiotherapy can be delivered by cobalt (using gamma rays from radioactive cobalt) or by linear accelerators (using x-rays). Linear accelerators have the advantage of higher beam energies, more accurate radiation delivery minimizing damage to superficial tissues and less scatter at the periphery of the radiation field. Current linear accelerators have the capability to deliver both photons and electrons and multiple energy levels are available to tailor the radiation to the needs of a given patient.

Brachytherapy
Brachytherapy is the modality in which radiation is delivered by placing the radiation source within the tissues to be irradiated. There are many ways of doing this: intracavitary radiation (for cancer of the uterine cervix), intraluminal radiation (esophageal cancer, nasophaynx, ano-rectum), and interstitial radiation (breast cancer, soft tissue tumors, etc.), surface mould (skin tumors, palate tumors, eyelid tumors, etc.).

Brachytherapy was previously delivered using manual methods but such methods have a high risk of radiation exposure to doctors, staff and patient's family members. Remote after loading devices are the preferred methods for Brachytherapy. Remote after loading systems can be low dose rate (LDR) or high dose rate (HDR).

High dose rate systems have many advantages: they are more state-of-the-art, precise, safe and take much less time. With HDR equipment, a given dose of radiation can be delivered in a method of minutes compared to hours and days for LDR equipment. This has many advantages for the patient, as patient isolation for a long period is not necessary with HDR equipment. Admission to the hospital can be avoided when using HDR Brachytherapy.

What are the side effects of radiation therapy?
Radiation therapy is a modality that has a low rate of complications or side effects if properly planned and administered. However, certain symptoms do appear during radiation and it is important to be aware of them so that undue alarm or panic is not created.

General symptoms
Patients undergoing radiation therapy can have general symptoms such as

  • Weakness
  • Fatigue
  • Loss of appetite
  • Nausea and vomiting
  • Anemia

Local symptoms

  • Irradiated skin has some degree of swelling and becomes sensitive. If subjected to local trauma at this stage, there can be peeling of skin and oozing.
  • Radiation to the head & neck area causes sensitivity in the mouth and throat (mucositis). This leads to some discomfort while swallowing. Attention to oro-dental hygiene and diet can usually minimize the symptoms and prevent development of secondary infections.
  • Radiation to the lungs can cause symptoms such as cough and shortness of breath.
  • Radiation to the abdomen can cause symptoms of nausea, vomiting and diarrhea.
  • Radiation to the pelvis can cause symptoms such as discomfort in passing urine, increased frequency of micturition, diarrhea, straining at stools, etc.
  • Radiation to any part of the body usually leads to loss of hair only in the area irradiated.

How can side effects of radiation be reduced?

There are two important approaches to reducing side effects of radiation therapy. One is the use of modern methods of radiation therapy planning and delivery and the other is the use of appropriate precautions as advised by the treating radiation oncologist.

Modern Methods in Radiation Therapy

With the availability of more powerful computers, two significant factors have contributed to advances in radiation oncology. One is the advance in imaging technologies. With more powerful CT scanners and MR imaging, a much more precise localization of the tumor and normal structures is possible at multiple levels of the body. This had led to the use of CT scan as the mode of choice for tumor localization and radiation field planning. The other change has been the development of more powerful radiation planning software that can utilize the sectional imaging information to develop more precise radiation plans that maximize the tumor dose, minimize the normal tissue dose and avoid dose heterogeneity within the radiation field. Three dimensional conformal radiation and intensity modulated radiotherapy has been the outcome of both these advances and are redefining the utility of radiation in management of cancer.

Precautions to be followed during radiotherapy:

  • Do not rub the skin markings, if any.
  • Do not apply anything (soap, powder, oil, cream) on the marked area / treated area.
  • Do not scratch the treated area.
  • If face is being treated, do not shave.
  • Avoid spices and chillies in diet
  • Do not smoke and do not take alcohol.
  • Wear loose, cotton clothes around treated area.
  • Take more fluids.
  • Follow all other instructions given by the treating doctor.
  • Consult your treating doctor once in a week for review.
  • Consult your treating doctor anytime you have any unexpected symptoms.

 

What is medical oncology?
Medial oncology is the youngest branch of oncology and it deals with treatment of cancer using medicines and is also the most rapidly developing branch with new breakthroughs coming almost every day.

The specialty primarily originated from the identification of cytotoxic chemicals developed as part of chemical warfare. The "mustard" gases developed around World War II were found to be strongly cytotoxic to human beings with very strong effects on the hematopoietic system. It was this observation that led to attempts to use these agents and their derivatives in hematological malignancies first and solid cancers later.

Medical Oncology has taken a major leap and now forms a very important part of multimodality management of almost all cancers and specially hematological malignancies.
Initially developed for the administration of cytotoxic agents, the specialty has expanded its scope remarkably with newer agents that use many different mechanisms to treat cancer.

What is the role of medical oncology in treatment of cancer?

  1. Haematologic malignancies such as leukemias (blood cancers), lymphoma and multiple myeloma are treated primarily with medicines.
  2. Some of the solid cancers are potentially curable with chemotherapy. Examples of this include germ cell tumors and gestational trophoblastic disease. In such cases, chemotherapy has become the prime modality of treatment and may be complemented by limited surgery.
  3. Adjuvant chemotherapy has become an important modality in the treatment of many solid cancers such as breast cancer, colorectal cancer, etc. Adjuvant use of chemotherapy is based on the concept of micrometastases that can not be identified with any current imaging modalities but are responsible for the majority of recurrences after potentially curative local therapy.
  4. Neoadjuvant chemotherapy is chemotherapy administered up front to achieve downstaging of tumor, before use of a local modality such as surgery or radiation. Neoadjuvant chemotherapy can be used to make the disease operable if it was inoperable before or permit the use of limited local therapy. In breast cancer, neoadjuvant chemotherapy can be used in locally advanced breast cancer to make the tumors operable. In early disease, it is used to increase the chances of breast conservation surgery.
  5. In a number of situations, chemotherapy and radiotherapy are being used at the same time (not one after another) to treat malignancies. Chemotherapy here serves to enhance the efficacy of radiation and thus lead to improved loco-regional control rates. In some cases, this approach permits the use of organ conservation strategies. This has been used adequately at MTMH for cancer sites like head and neck cancers, cervix, lung and oesophagus.
  6. Palliative chemotherapy is a very important modality to improve the quality of life of a large proportion of cancer patients who present with advanced disease that is not amenable to curative treatment with surgery and/or radiotherapy. Here, chemotherapy can improve distressing symptoms and also lead to some prolongation of survival with good quality of life.

What are the medicines used in medical oncology?

Cytotoxic chemotherapy
Conventional chemotherapy drugs that kill dividing cells in the body. Since cancer cells are almost always rapidly dividing, they are preferentially killed.

Hormones and hormone antagonists
Hormonal antagonists and agonists have been very useful in the management of breast cancer in women and prostate cancer in men. A number of exciting new agents are becoming available that are enhancing the role of such interventions.

High dose chemotherapy
High dose chemotherapy is the use of more than the standard doses of chemotherapy and it is used in the management of more aggressive, relapsed, or advanced cancers that are often non-responsive to standard dose of chemotherapy.

Biological agents e.g. interferons, interleukins, etc
A number of biological agents such as interferons and interleukins have been found to have activity against some cancers. These agents have been particularly useful in the management of chronic myeloid leukemia, cancer of the kidney, superficial bladder cancers (follicular), non-Hodgkin lymphoma (follicular), Hairy cell leukemia, etc.

Immunotherapy: monoclonal antibodies.
A promising new field where exciting advances are taking place. Two monoclonal antibodies are currently available in the country (Trastuzumab or Herceptin for breast cancer, and rituximab or Mabthera for hematological maligancies).

Gene therapy
Gene mutations are at the root of all cancers. Interventions at the genetic level are thus very attractive. Lot of research work has been going on and some products are expected to come into clinical practice soon.

Signal transduction inhibitors
Drugs such as tyrosine kinase inhibitors, anti angiogenesis drugs, farnesyl transferase inhibitors, etc are very tempting because they have the promise of being effective with oral administration and have negligible systemic toxicity. One of the top success stories is a new drug Gleevac (Imatinib) that has shown very high efficacy in chronic myeloid leukemia in all phases of disease. Newer products are expected to be available soon for a variety of cancers.

  • Vascular access devices (ports / central lines).
  • Arterial and Venous Pumps (elastomeric and / or electronic pumps).
  • Growth factors to take care of low blood counts (febrile neutropenia).
  • Blood component therapy including single donor platelets.
  • Chemo-protectors

 

What is surgical oncology?

Surgical Oncology refers to the branch of medicine involved in treatment of cancers by surgery. Surgery was the first modality to be used in the treatment of cancer. With the developments of general anesthesia in the 19th century, major surgical procedures that are necessary for the treatment of cancer became possible. With advances in pre- and post-operative care, blood transfusion, antisepsis and development of antibiotics, such surgical procedures could be carried out with very low complication rates and negligible chances of death due to treatment. This led to an explosion in the field of surgical management of cancer. Originally, surgical treatment of cancers was carried out by general surgeons and other surgical specialists. Extensive surgical resections complemented with plastic and reconstructive surgery have been successful in the management of a large variety of cancers at all stages. Surgeons dedicated exclusively to cancer care are known as surgical oncologists.

Why should one prefer dedicated cancer surgeons?

With developments in the field of oncology leading to integration of multimodality management, it has become imperative that a surgeon dedicated exclusively to cancer care be involved in the surgical management of cancers in all cases. This leads to improved patient outcome in terms of better diagnostic and staging assessment, proper integration of surgical and non-surgical treatments, customization of surgery to the needs of the patient (extensive surgery in some cases to get cures and limited surgery in other cases for organ and function conservation).

Does surgery lead to a flare in the disease?

This is a dangerous misconception among the public. There is no evidence that surgery for cancer patients leads to the disease flaring up or becoming more aggressive. Because of this fear, a large number of cancer patients do not undergo the appropriate treatment at the right time. Delay often leads to the disease becoming advanced and the opportunity for cure is lost.

The basic nature of cancer is to grow. Often, there are cancer cells remaining in the body after the surgery even when the complete tumor has been removed adequately by surgery with a wide margin. These cells would grow over period of time and lead to the disease coming back. However, the recurrence is not caused by surgery. It is the inherent nature of disease.

Such remaining cancer cells need to be taken care of by post-operative adjuvant therapy such as radiotherapy or chemotherapy that significantly reduces the chances of the disease coming back. Currently, a large percentage of patients need to be treated with post-operative adjuvant therapy, either chemotherapy or radiation therapy or both to minimize the chances of disease recurrence. Thus, every cancer patient should have his case discussed in the tumor board after apparently complete surgery to decide about the need for further therapy.

It must be stressed that surgical treatment is one of the basic components of curative treatment in nearly all solid cancers. Often, if a patient's disease is inoperable, it may be beyond the chance of cure.

Is cancer surgery very disfiguring?

No! Cancer surgery is not a disfiguring surgery as it is practiced today. With the progress that has happened in the last century, majority of cancers can be managed without disfigurement.
One of the reasons for this is significant progress in plastic and reconstructive surgery. Use of various types of plastic surgical procedures leads to excellent cosmetic outcome and good functional status in almost all cases of cancer. In fact, it is possible to use plastic surgery to reconstruct breasts after they have been removed for breast cancer.
A thorough knowledge of plastic surgical procedures available and their application in the management of different cancers is another factor that distinguishes cancer surgeons. Proper selection of the plastic surgical reconstruction in a given case can make a lot of difference to the outcome.

Is cancer surgery very risky?

With the supportive services at the disposal of a surgeon in current times, the risk involved in major surgeries required for cancer treatment has become negligible. In fact, there are large series of a number of different major surgeries where there is no loss of life related to the surgical treatment.
There has been a significant reduction in the complication and mortality rates related to major surgeries over the last 20 to 30 years. Surgery for esophageal cancer can now be carried out with a mortality of less than 5%. Resection of liver, pancreatic surgery, extensive pelvic surgery, etc. can all be carried out now at low mortality rates if the modern methods of pre- and post-operative care are combined with a good surgical procedure.

What is the role of cancer surgery?

Surgery can be used for various purposes in the treatment of cancer.

Diagnosis: Biopsy of different tumors is a pre-requisite to treatment. Biopsy allows confirmation of malignancy and allows accurate typing of tumor. Nowadays, fine needle aspiration cytology (FNAC) is the preferred first investigation and biopsy is carried out if required. Biopsy can be incisional or excisional. Sometimes, frozen section examination is done to get intra-operative confirmation of diagnosis and carry out the necessary surgical treatment under the same anesthesia.

Curative Surgery: Surgery for cure of cancer is used in most of the solid cancers of the body e.g. cancers of the head & neck, salivary glands, thyroid, breast, lung and esophagus, liver, gastro-intestinal tract, kidney, urinary bladder and prostate, ovary, uterus and cervix, bone and soft tissues, external genitalia, etc. In a number of these cases, surgery may be followed by further treatment with radiation or chemotherapy to consolidate the gains.

Supportive and Palliative Surgery: Sometimes, surgery is required for relief of symptoms without cure of disease. Tracheostomy, feeding gastrostomy and jejunostomy, colostomy, and many such surgical procedures are carried out to provide relief of symptoms and be lifesaving without curing the disease. Surgery can also be done for control of bleeding from the tumor. Venous access surgery like placement of venous ports makes it easier for medical oncologists to do repeated administration of chemotherapy without causing distress to the patient. Arterial ports may be placed for intra-arterial chemotherapy.

Is cancer surgery very costly?

It is not so. In fact, a surgery carried out for cancer of any part is no more costly than a similar surgery carried out for non-cancerous diseases of the same area of body. Today, surgery for breast cancer is carried out at DCHRC at about the same cost as the surgery for gall bladder stones. There are a number of major surgical procedures in cancer surgery that are more extensive that surgery for non-cancerous diseases. In such cases, longer hospital stay may also be required and the overall cost of treatment may be slightly higher. Overall, at DCHRC, our objective is to minimize the hospital stay and treatment costs for the patients. With this in mind, one of the approaches followed is to minimize pre-operative hospital stay. Patients are many times called in the morning of surgery for admission if they do not have significant medical illness or do not need pre-operative preparation. Similarly, post-operative care is standardized to minimize post-operative hospital stay.

Source: TMH, Mumbai

 

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