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Cancer:
Types, Symptoms, Risk Factors, Diagnosis and Treatment

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1.Cancer prevalence in India

As India strides into the 21st century, the spectrum of disease has changed from mainly infectious diseases to more chronic disease (such as heart disease & diabetes), while cancer has assumed epidemic-like proportions. This is due partly to lack of awareness of health promotion & disease prevention as well as lack of amenities for early diagnosis and treatment.

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2.Types of Cancer

Cancer refers to an abnormal & unregulated growth of tissue, which may invade surrounding normal structures as well as spread to sites distant from that of origin. Cancers are broadly of 3 types:

  1. Carcinomas (70%) : arise in membranes (coverings) and glands/ ducts of glands; commonest type of cancer; usually spreads to neighbouring sites, then to distant sites; important sites include head-neck, lung , prostate, breast, oesophagus, colorectum & anus
  2. Sarcomas (10-20%): arise from bone/muscle/nerve; less common; spreads to distant sites early
  3. Blood cancers: Leukemia , Lymphoma & Myeloma

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3.Common cancers

The commonest cancers worldwide in men are Lung Cancer & Prostate Cancer, and in women, are Breast Cancer and Lung Cancer. However, in India, the commonest cancers in men are Head-Neck cancers (especially Oral cancers in the Eastern part of the country), while in women, the commonest cancer is Uterine cervical cancer.

Ironically, both of these are preventable diseases, since head-neck cancers are almost always related with use of tobacco, while cervical cancer arises from chronic infection by Human Papilloma Virus.

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4.Symptoms of Common Cancers :What to watch out for

Cancer Symptomss

Causes of cervical cancer can be attributed to the genetic mutations that occur in the healthy cells of the cervical tissue. Normal cells multiply, grow and die at a certain rate. Mutations in the DNA changes the fundamental life cycle of the cervical cells that accumulate over time to form a mass, known as the cancerous tumor.

Symptoms of Breast Cancer

  • Breast lump
  • Skin changes/ ulcer over breast
  • Nipple retraction
  • Discharge/ bleeding from nipple
  • Swelling in axilla (armpit)
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

Symptoms of Head & Neck Cancers

  • Non-healing mouth ulcer
  • Swallowing difficulty
  • Hoarse voice
  • Chronic cough
  • Hemoptysis (blood with sputum)
  • Neck swelling
  • Pain in throat
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

Symptoms of Lung Cancer

  • Breathlessness
  • Chest pain
  • Chronic cough
  • Hemoptysis
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

Symptoms of Brain Tumors

Symptoms of cancers of GI tract

  • Dyspepsia (acidity, indigestion, heartburn)
  • Vomiting & blood-vomiting (hematemesis)
  • Black stool (melena)
  • Bleeding per rectum
  • Lump abdomen
  • Ascites
  • Pain abdomen
  • Pain during defecation
  • Jaundice
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

Symptoms of urinary cancers

  • Hematuria
  • Pain abdomen
  • Frequency of urine & nocturia
  • Pain during passage of urine (dysuria)
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

Symptoms of gynaecological cancers

  • Bleeding PV
  • Vaginal discharge
  • Pain abdomen
  • Other symptoms may appear if the cancer spreads to liver/ lungs/ brain/ bone

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5.Cancer prevention

  1. Avoiding smoking and other tobacco products (khaini, etc) can prevent many cancers (head-neck, lung, urinary bladder, etc) as well as chronic heart & lung diseases
  2. Lower consumption of red meat & processed meat
  3. Increased consumption of green, leafy vegetables
  4. Vaccination against Human Papilloma Virus (prevents cervical cancer) & Hepatitis B virus (prevents chronic liver disease & liver cancer)

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6.Cancer screening

Cancer Screening

Many diseases can be diagnosed at a very early stage, even before they produce symptoms, and when treatment will have a much greater benefit. Such diseases can be actively searched for in the general population by a process called “screening”.

Successful screening is possible for:

  • Cervical cancer (All women in reproductive age group should have a Pap smear done annually),
  • Prostate cancer (All men beyond age 50 years should have an annual blood test called PSA) and
  • Breast cancer (All women beyond age 40 should have an annual X-ray of the breasts, called Mammography).

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7.Cancer detection

Cancer symptoms vary according to the site of disease. However, any abnormal lump/ sore anywhere in the body, along with any abnormal bleeding or discharge needs to be reported to the nearest community physician, who can then arrange for further investigations & hospital consultations. Cancer often requires a battery of tests, including blood tests, X Rays, endoscopies, CT scan/MRI scan. Cancer diagnosis almost always involves getting a tissue/ cell sample from the suspicious growth, called a biopsy.

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8.Treatment

Various treatment modalities are required in treatment of common cancers. These include surgery, radiotherapy & chemotherapy/ targeted therapy.

Surgery involves operative removal of the tumor with a margin of healthy tissue and most centres have specialized surgeons for each organ system of the body. Radiotherapy refers to treatment of cancers by X-rays & Gamma rays, from outside the body (teletherapy) or inside (brachytherapy). Chemotherapy & targeted therapy are systemic treatments acting on the entire body, usually to prevent or tackle disseminated disease.

Treatment modality varies according to site & stage of disease. Many common cancers in stage I or II can be treated by single modality, either surgery or radiotherapy. More advanced disease usually will also require systemic therapy (chemotherapy/targeted therapy), while metastatic disease & blood cancers are almost solely treated by such systemic therapy.

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9.Challenges in cancer control in India

Till now, the focus has been on treating cancer, less on prevention and even on diagnosis. This is wrong because some cancers can be prevented and many cancers can be treated more effectively if diagnosed early. We need to evolve a more organized network of primary care providers, who can be involved with a particular community on a continuous basis. This demands proper funding and education of the primary care providers and a systematic division of the population according to catchment area, amongst them.

Even in the treatment of cancers, India is running far behind in the number of institutes, doctors, other staff and equipment necessary to deal with the hordes of patients. The situation cries out for increased funding on cancer care, setting up of new institutes and training of more staff than available at present. Cancer care is an expensive business and too often the patient’s ability to take and comply with treatment is undermined by their inability to pay. Subsidised government institutes alone cannot cope with the demand…resources must be pooled. There needs to be a supervising authority in cancer care in every state, to guide the patients so that they can get the right treatment at the right time.

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10.Modern Radiotherapy Techniques

Cancer Screening
  • MRT (Intensity Modulated Radiotherapy)
  • VMAT (Volume Modulated Arc Therapy)
  • IGRT (Image Guided Radiotherapy)
  • SRS/SRT (Stereotactic Radiosurgery & Radiotherapy) [Cranial]
  • SBRT (Stereotactic Body Radiotherapy)

How do Modern Radiotherapy Techniques optimise cancer outcomes?

  • By providing superior toxicity profile in existing successful treatment settings, eg IMRT reduces xerostomia (dryness of mouth) in head-neck cancer
  • By enabling superior tumor control in existing treatment settings, eg IMRT & IGRT enable dose escalation in prostate cancer, leading to superior disease control
  • By providing disease control solutions in innovative treatment settings, eg SBRT for hepatocellular carcinoma

IMRT

  • Is a form of treatment delivery to achieve highly conformal dose distribution, ie treatment dose fits on the target & spares normal tissue as far as possible
  • Uses complex dose prescription techniques, called Inverse Planning, whereby the physician is able to specify desired dose-constraints to the target & normal tissues

Parotid dose, xerostomia & IMRT

  • With conventional radiotherapy in head-neck cancer, all patients undergo irradiation of parotid glands to a high dose, leading to irreversibly damaged function: this leads to permanent dryness of mouth
  • Research has shown Severe xerostomia (<25% of baseline) avoided if mean parotid dose kept to <20Gy (if one parotid is to be spared) or <25 Gy (if both are to be spared)
  • IMRT enables parotid sparing and reduces the possibility of long-term xerostomia
  • Thus patients are able to achieve complete recovery of salivary function, facilitating better swallowing & speech functions, hence allowing for a better quality of life
  • Research has also established that sparing of the parotid glands does not negatively impact tumor control.

IMRT for prostate cancer

  • Radical radiotherapy is the curative option for organ-confined prostate cancer
  • Radiotherapy dose escalation has been shown to improve disease control rates
  • IMRT allows RT dose escalation while controlling doses to the adjacent anterior wall of the rectum
  • Thus, IMRT in prostate cancer enables superior disease control with tolerable toxicity profile (rates of late radiation proctitis, causing bleeding per rectum are <5%)

IMRT & VMAT

  • The linear accelerator treatment head has an array of small blocks called Multi-Leaf Collimators (MLCs).
  • During IMRT delivery, the MLCs shape the beam aperture in a combination of different irregular shapes. Delivery is comparatively slower at 15-20 minutes.
  • VMAT is a more sophisticated form of IMRT, where not only is treatment more focused but it allows comparatively much faster treatment delivery, within 2-2.5 minutes.
  • Faster treatment minimises patient movement & maximises comfort.

IGRT

  • Image guided radiotherapy is a broad concept whereby frequent imaging is done in the treatment room for more accurate treatment delivery.
  • IGRT is mainly to ensure accurate patient positioning and overcoming problems due to organ motion.
  • Due to variations in patient setup & organ motion, an extra margin of tissue has to be radiated to deliver adequate dose to the tumor
  • IGRT can help us to eliminate or at least, reduce this margin
  • This results in much less normal tissue being irradiated to high doses

Stereotactic radiotherapy

  • Refers to extremely accurate localisation of a point in space
  • Stereotactic radiotherapy refers to a technique of extremely focused radiotherapy
  • It is usually delivered in a small number of fractions (1-5), with large dose/fraction (>4Gy/#), unlike conventional radiotherapy which is delivered in small doses over a long time (1.8-2Gy/#, once a day, 5 days a week for 5-7 weeks).
  • Delivering a much higher dose over a shorter course of time, allows the radiation to be more effective biologically.
  • The effect of stereotactic radiotherapy is akin to surgery.
  • Stereotaxy was first achieved in cranial lesions, many of them benign, eg arterio-venous malformations, craniopharyngeoma , pituitary adenoma & acoustic neuroma
  • These all feature treatment of a small target, adjacent to vital areas, to a dose much higher than the tolerance dose of nearby structures.
  • Stereotactic radiotherapy is today, also the preferred treatment modality for brain metastases. It has been shown to be equivalent to surgery or whole brain radiotherapy.
  • The first machine to deliver stereotactic radiotherapy was the Gamma knife, created by Lars Leksell (a neurosurgeon) in 1961. This machine uses 201 small telecobalt sources.
  • Today, cranial stereotaxy can also be delivered by specially equipped linear accelerators (the so-called X-knife)
  • Cranial stereotaxy initially was based on physically & invasively fixing a rigid frame to the patient’s cranium.
  • The frame was required for the accurate localisation of the target on imaging.
  • In the modern day, we have come to use non-invasive frames.
  • Use of sophisticated pre-treatment imaging, such as in-room Cone Beam CT, has allowed us to do away with frames altogether.

SBRT

  • Also called Stereotactic Ablative Body Radiotherapy (SABR)
  • Extracranial stereotaxy has become possible because of Image Guidance in the treatment room
  • SBRT is done for tumors of the lung, liver, pancreas, prostate & spine.
  • SBRT is the most exciting recent development in lung cancer therapy. Early lung cancers, though rare, are curable by surgery. However, many such patients have severe COPD & other medical comorbidities, precluding surgery. SBRT has provided an alternative to these patients. It has been shown to be as effective as surgery for local control.
  • SBRT to the liver/lung metastases achieves superior local control, as compared to using systemic therapy (chemotherapy) alone
  • More feasible than surgery for patients with poorer performance status / with less accessible lesions

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11.Radiotherapy Quickfacts

  • Radiotherapy is not a form of heat; it will not burn you. It is a form of treatment using high-energy X rays to destroy cancer cells.
  • After radiotherapy, side effects common in the head-neck region are darkening/ peeling of skin, mouth ulcers, difficulty in swallowing and dry mouth. Of these, the first three recover rapidly in a couple of weeks after completion of radiotherapy. Dry mouth may persist for longer, may take upto 2 years to normalize, may not completely return to pre-RT status.
  • Common side-effects for breast/chest wall radiation are darkening/ peeling of skin and itching, which should go away within a few weeks of completing radiotherapy.
  • Common side-effects for pelvis radiation are indigestion, diarrhea and vomiting which should go away within a few weeks of completing radiotherapy.
  • Side effects of concurrent chemotherapy are nausea/vomiting and low blood counts, which may lead to infections and fever. Always inform in case of any fever, diarrhea, vomiting.
  • During radiotherapy, avoid rubbing/ applying soap or oil on the irradiated area. You are free to have a bath with water. Drink plenty of water (3 litres/ day).
  • For head-neck radiotherapy, use soft brush and mouthwash hourly with salt-soda solution. Men should not shave. Do not wear shirts with collars.

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12.Why Narayana Health?

All the cancer treatment modalities are available here, including:

  • Surgical Oncology (with site-specific teams)
  • Medical Oncology (chemotherapy & targeted therapy for all common cancer sites)
  • Radiation Oncology/ Radiotherapy (with state-of-the-art facilities for both teletherapy & brachytherapy) &
  • Hemato-oncology (for treatment of blood cancers, including a soon-to-start Bone Marrow Transplant Unit).

Cancer calls for multi-modality therapy and frequently specialists from all the branches of oncology are involved in the care of the cancer patient. It is essential that every patient is seen after diagnosis by all the specialists who can then chalk out an optimal treatment plan. This is why, at NH Cancer Institute, we have a Multidisciplinary Tumor Board for all cancer patients, attended by the relevant members of the oncology team.

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13.Cancer FAQs: All you need to know

Q.  Is cancer common?

  1. As per stats, around 1300 Indians die of cancer every year. Most of the risk of contracting cancer comes from a person’s lifestyle. Consequently, reducing the risk of cancer can also come from bringing about a change in a person’s lifestyle such as avoiding tobacco and alcohol and limiting exposure to the sun. Moreover, screening tests also help in detecting early signs of cancer.

Q.  Who is more at risk of cancer?

  1. Research finds out that in India, men are more susceptible to cancer than women. However, when it comes to the mortality rate, men have a low life-expectancy of 75% as compared to women, who are at 60%. Moreover, when it comes to age, 9 out of 10 cancers are found in people who are 50 years or older. Although cancer exists among all racial and ethnic groups, however, the rate of occurrence, also known as incidence rate, is different in each group.

Q.  What causes cancer?

  1. Some of the primary causes of cancer are as follows:
  • Lifestyle factors such as tobacco and alcohol
  • Being exposed to radiation therapy or sun rays for a prolonged time
  • Genetic reasons’; as per stats, 5-10% of all cancers are linked to genes inherited from parents.

Q.  Can you get cancer from stress?

  1. Research finds out that there is no particular connection between a person’s personality and the risk of cancer. There are several aspects that exist between the connection between stress and cancer. An excess of stress can affect the immune system, but it’s not the only factor affecting it. Till date, no empirical data has been found that can connect stress to cancer.

Q.  What are the risks associated with cancer? Make it risk factors

  1. Risk is something that can increase your chances of a disease, in this case, cancer. The risk factor is different in different types of cancer. For example, prolonged exposure to sunlight can put you at risk of skin cancer, however, it’s not going to increase your chances of colon cancer. Although, risk factors are not a clear indication of you contracting cancer. Among the several risk factors out there, some of the common ones are:
  • Tobacco consumption
  • Alcohol consumption
  • Diet
  • Physical weight
  • Exposure to sunlight
  • Environmental exposures such as lead and asbestos
  • Exposure to infections such as hepatitis and HIV

Q.  Is it possible to prevent cancer?

  1. Although it’s not possible to prevent cancer, there are several ways to reduce the risks of cancer:
  • Limiting the use of tobacco
  • Limiting the use of alcohol
  • Limiting exposure to the sun and ultraviolet rays
  • Dietary changes such as including green vegetables and limiting processed meat

Q.  How can cancer be treated?

  1. There are three treatment methodologies that can be used to reduce the effects of cancer:
  • Surgery - This is the first treatment procedure applied to help remove the cancerous portion in the body
  • Chemotherapy - This method is used to kill the cancer cells with the help of an intravenous injection or a pill.
  • Radiation therapy - This aims to provide high energy rays such as X-rays to reduce or shrink the cancer cells.

Q.  What are the first signs of cancer?

  1. Although every cancer case is different, here are some of the general initial signs and symptoms that you have to look out for:
  2. Weight loss: If you experience a sudden weight loss of 5 kilos or more, within a short period, it can be a sign of cancer. Weight loss is quite common in people who are suffering from pancreatic, oesophagal, or lung cancer.
  3. Fever: Fever usually takes place when cancer has metastasized and it is usually paired with night sweats.
  4. Fatigue: Extreme tiredness can be a sign of cancer growing in your body
  5. Skin pigmentation: Yellowing or redness of the skin can signal to cancer. Especially, for breast cancer and lymph nodes.
  6. Pain- Mostly, pain occurs because cancer has spread to major parts of the body. Usually, it’s an early symptom for patients suffering from bone and testicular cancer.

Q.  Can cancer go undetected for a long period?

  1. There are instances where cancer goes undetected for a long period, sometimes a decade. Studies conducted at Stanford University School of Medicine have provided new evidence that malignant tumours can grow undetected within the body, but they can be found out with the help of a sophisticated series of blood tests.

Q.  Can cancer go away on its own?

  1. Cancers do not just go away, and of course, nobody is suggesting that you avoid treatment because of occasional occurrences. Cancer will not just go away on its own, it needs intensive treatment for it to go into remission. Its better than the disease is identified and treated in the early stages, this way the chances of remission are significantly improved.

Q.  Can cancer show up in blood work?

  1. Yes, there are many examples of blood tests that are used to diagnose cancer. Some of them are Complete Blood Count (CBC), which helps detect blood cancers; this test will find out if there are too many or too few blood cells or abnormal cells found. A bone marrow biopsy can help with diagnosing blood cancer.

Q.  What is cancer fatigue?

  1. Cancer-related fatigue is not the regular feeling of tiredness that people experience, this fatigue is quite intense. This type of lethargy leaves people feeling weak, drained, or listless. Some may feel too tired to perform basic functions like eating or having a shower; they may even find it difficult to lift the TV remote or move from one place to another.

Q.  Which is the most painful cancer?

  1. Bone cancer has to be the most painful type of cancer. The patient will usually feel tenderness, with constant pain along with muscle spasms. Patients suffering from breast or prostate cancer will often suffer from rib fractures as well. This is due to rib metastases.

Q.  What will happen if you don’t treat cancer in time?

  1. If the cancer is allowed to spread, without any treatment, then the symptoms will get worse and new signs will creep up over time. The cancer cells will spread to all the vital organs and start interfering with basic body functions that are required to live. Untreated cancer will lead to death.

Q.  How can you live cancer-free?

  1. Follow these healthy steps to keep cancer away:
  • Eat a healthy and nutritious diet
  • Don’t smoke tobacco
  • Maintain a healthy weight
  • Skip alcohol
  • Have a consistent workout regime
  • Manage stress by attending a cancer survivor joint group

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