Dr Vishala Rose Marie Varghese
One of the things that kind of surprised me as I practice oncology here in Nagaland is usually the response of patients when they are told they are having cancer. Their next question will be “Ma’am, what do you recommend we eat?”I am usually shocked and sometimes wonder if they have understood what I just said or if they are totally unaware of what cancer is. While I was doing my MD Radiation Oncology in CMC, Vellore, the first reaction to the word “cancer” was usually of shock and disbelief. I have had patients crying, beating their chests and wailing and howling in OPD when they were told about their diagnosis. Which makes it even more difficult when you have to tell them the next worst part…the stage of the cancer! Especially, if it’s an end stage cancer with no chances of cure in sight, it makes that much more difficult to break the news to the patient. Well, while I would say both reactions I have encountered to the diagnosis are two extremes of the poles, both are definitely not right way and which is why I have chosen to write to clear up some misconceptions about cancer.
First, what is cancer? I will tell you what it is and what it isn’t. Cancer is, to put it simply, a rapid growth of abnormal cells, which can sometimes spread to other parts of the body. I will tell you what it isn’t-- cancer is not always a death sentence! It need not be, provided that you report to the doctor at the earliest with your symptoms. Symptoms of cancer vary depending on the site at which it is present. If a patient has a cancer of the food pipe (esophagus), then he will have pain or difficulty in swallowing. If it’s a head and neck cancer, most patients present with a swelling in the neck region which can be painless and can grow progressively over a period of months. A lady with breast cancer will complain of a lump in the breast. There may or may not be pain or any discharge from the nipple. A patient with colon or rectal cancer may complain of bleeding from the anus or whitish discharge or altered bowel habits. The complaints of the patient depends on where the cancer is primarily located. Sometimes if it spreads to other parts of the body, we call it as “metastasis” or “mets” for short, and the patient can have complaints of that particular site of mets. For example, a breast cancer patient with lung mets can have breathing difficulty depending on the size and number of mets.
Two things which are important for any oncologist to know are the stage and type of cancer. The stage of the disease can be said by an imaging (CT scan, MRI or PET CT). Cancer can only be confirmed by a biopsy, which can tell us the type of cancer. Imaging mostly tells us where the cancer is and how much it has spread. It is not confirmatory of cancer. Biopsy confirms cancer. Biopsy is taking a small piece of tissue from the site of cancer for testing. Cytology is taking cells and sending for testing. As an oncologist, I would prefer a biopsy any day over a cytology as it’s more accurate. Also, the type of cancer reported changes the line of treatment I may choose to give.
Stage I-III is usually localized cancer. It means it is within the local site and has not spread anywhere else. Stage IV is usually when it has spread from one organ to another. Cancer cells can travel through blood and get deposited in liver, lungs, bones, brain etc. The earlier the cancer stage, the better. Which is why we usually recommend patients to see their doctor at the earliest when they develop symptoms to avoid it spreading to other organs. Like I said previously, Stage IV doesn’t necessarily mean that it’s a death sentence. With the advancement of science and technology, newer and better treatment options have opened up, which continue to give hope to cancer patients everywhere. Every advancement in cancer is aimed at prolonging the life of cancer patients, if the disease cannot be cured.
I have had patients ask me if I could prescribe medications for their cancer treatment. Unlike other diseases, there are no medications available for cancer. Cancer involves more of a multi-modality approach. It’s not just one specialty that takes care of it. When it comes to solid organ cancers, to be precise, it would mostly be three—surgical oncology, medical oncology and radiation oncology. There are only three known treatment for cancer—surgery, radiation therapy and systemic therapy (which includes chemotherapy and targeted therapy). Blood cancers are mostly managed by hemat-oncologists and mostly require chemo, bone marrow transplant and in some cases radiation therapy.
Chemotherapy is given intravenous (i.v.) drugs which are specifically targeted to kill the cancer cells. There are also oral chemotherapy drugs available. Radiation therapy (RT) involves giving X-rays to kill the cancer cells through a machine known as “Linear accelerator” (LINAC). Patient is made to lie on a couch and the target region of cancer is treated. It’s almost like getting a CT scan done—there’s absolutely no pain and treatment gets over in 5 to 10 mins and usually happens over 5 days in a week for 5-6 weeks, depending on the site and stage.
There’s no one-size-fits-all when it comes to treatment for cancer. Treatment varies depending on the type of cancer, the type and the stage. I have given examples for a few common sites seen here in Nagaland. In oral cavity cancer, if it’s Stage I or II, surgery or RT(Radiation therapy) will do. If its Stage III or early stage IV, we may consider giving a few cycles of chemotherapy followed by surgery (if feasible) followed by radiation therapy (+/- chemotherapy, as indicated). For Nasopharynx, which is one of the most common head and neck cancer seen in Nagaland, there is no role of surgery in the radical setting as the nasopharynx is anatomically not in a site that is very easy to operate. So if its Stage I or II, radiotherapy alone or radiotherapy +chemotherapy should suffice. If its stage III or early Stage IV , the usual protocol would be to give 3 cycles of chemotherapy followed by followed by radiation therapy + chemotherapy. In the case of breast cancer, treatment is divided based on early and locally advanced stage. In early, we can go for upfront surgery followed by chemotherapy and hormonal therapy. If patient opts not to have her whole breast removed and only the lump, then she will need RT also. In locally advanced stage, the usual protocol is chemotherapy, followed by surgery followed by RT.In the scenario of ca cervix (which is a type of uterine cancer), in early stage (upto Stage II), surgery is preferred. Chemo and radiation are given based on certain features on the post-surgery report. From stage II and above, there is no role of surgery and the mainstay of treatment is chemotherapy and radiation therapy. So as you can see, treatment options are as varied as the sites, types and stage of cancer.
Another important question that comes up is….what causes cancer? There are many factors…some known, some unknown. Smoking and alcohol consumption are the main causes of most cancers seen. Genetics also plays a role. there is a common mutation known as “BRCA mutation” in breast, ovarian and endometrial cancer that has been attributed to genetics. Testing for the same can be done but some tests are not available here and the available ones are expensive too.
Do food habits play a role? They do but to what extent, would be difficult to say. One of the contributing factors to breast and endometrial cancer is obesity, so yes, food can play a role. Spicy and salty food has been implicated as a cause for stomach cancer.
So, the question is…how do you know when its cancer and when it’s not? It’s really hard to tell because as I mentioned earlier, it all depends on the site of the cancer. Some sites have very vague presentations, like ca ovary for example, where mostly the complaints of the patient will be weight loss, loss of appetite and bloating. Most patients don’t take it seriously and attribute it to other reasons. Only when symptoms worsen, do they end up visiting a doctor and are then found to be in the last stage of cancer. So in any case, the earlier you present to the doctor, the better. It’s difficult to say what specific symptoms to watch out for. But for one, any swelling anywhere in the body needs to be investigated immediately. It cannot wait. Whether it's a neck swelling or a lump in the breast, the person should see a doctor immediately. It may prove to be benign but its better to be safe than sorry always. Significant weight loss too is also a cause for concern. That would be defined as more than 10% weight loss in 6 months. Especially if its accompanied with loss of appetite and fatigue. If there is any history of family malignancy, it would be good to get screening done at regular intervals. Your oncologist would be able to help you with that decision.
Overall, cancer need not be a death sentence, if picked up early. And it need not be something to be scared of. With treatment options and techniques evolving these days, it no longer be as scary as it used to be once. But always remember, prevention is always better than cure. Adopting the right lifestyle and getting yourself checked or screened on time should be the way forward.
The writer is MD (Radiotherapy), Junior Consultant, Department of Radiotherapy, CIHSR, Dimapur.
