NH cares

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

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

• Headache
• Weakness in limbs
• Visual problems
• Speech problems
• Convulsions
• Loss of consciousness
• Difficulty in walking
• Loss of co-ordination

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

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).

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.

• 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 (
• 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

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

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.