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All Cancers Are Not The Same!

Dr.Karthik Chandra Vallam

Dr.Karthik Chandra Vallam, MBBS, M.Ch., DNB, Surgical Oncologist

Contrary to widespread belief, Cancer is not the same in every patient. Just as there are so many parts in the human body, there are thousands of cancer variants a person can get affected with.

The two key determinants of outcomes of cancer therapy are the BODY ORGAN which is involved and the STAGE at which it is detected in the patient.

Cancers are basically divided into solid organ cancers and hematological (blood and lymphatic system) cancers. The survival of a patient differs where it affects, thyroid/brain/lung/kidney/gallbladder/intestine/bones/blood etc.. Most of the solid organ cancers which have not metastasized (spread to other parts of the body) are treated with surgery, sometimes with radiation and many times with a combination of surgery, radiation, and chemotherapy. Meanwhile, chemotherapy is the mainstay of treatment in hematological cancers, occasionally supplemented by radiotherapy and very rarely with surgery.

Cancers are usually categorized into four stages with stage one being the earliest and stage four being the last stage where patients are not expected to live long and usually have a tumultuous few months to live. In well-developed nations, due to better education, awareness, and access to good healthcare facilities, cancers are detected in an early stage whereas, in underdeveloped countries and underprivileged socioeconomic groups, cancers are usually detected in late stages leading to poor outcomes.

It is difficult to predict the outcome of treatment for cancer. For example, a variant of thyroid cancer called papillary cancer has very good treatment outcome and most of these patients live a normal and uncomplicated life. The same is the case with early stage breast cancer. Whereas, lung cancers are usually detected in a late stage and most patients succumb to it within a few months of diagnosis. The treatment of blood cancers is usually prolonged and requires multiple cycles of chemotherapy, complicated bone marrow, and stem cell transplants, immuno-suppression related complications, high cost, etc., which makes treating these patients a challenge. Cancer specialists gain experience over time and are able to predict and treat better.

Cancer patients need to be evaluated with multiple tests initially to accurately diagnose and predict the stage of cancer which often takes a few days to a couple of weeks during which period the patients and their relatives experience a lot of anxiety. The exact identification of site, variant, and the stage is key to chalk out the appropriate treatment plan. This is best achieved in experienced cancer centers with trained and experienced group of oncologists who hold tumor-board discussions before finalizing treatment plans.

So, it is important NOT to generalize all cancers and to treat each patient as unique and advise as per that specific patient’s condition.

CORE POINT: Cancer is an imminently curable condition when detected at an early stage and treated by good oncologists at an established cancer center like Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam.

Written by 
Dr. Karthik Chandra Vallam,
MS, M.Ch., DNB, Surgical Oncologist, Robotic and Laparoscopic Surgeon,
Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam.

Pathology At The Forefront Of Advances In Oncology

Dr.G.Veniprasanna

Dr. G. VeniPrasanna, M.D., Pathologist

The practice of pathology and its role in cancer care has changed significantly in the past decade. In the olden days, it was limited to a microscope and a few special stains. Immunohistochemistry (IHC) arrived after that to advance diagnosis and treatment capabilities.

The current treatment landscape is ever so changing – the era of chemotherapy changed to an era of precision medicine / personalized medicine. “One size fits all” (the approach of chemotherapy) is no longer valid. Each tumor is unique in its own genetic/molecular subtypes. Identifying driver mutation which drives the growth of cancer predominantly and thus also becomes a target for treatment is the present focus of cancer research. The best example is lung cancer. In the past, the major types of lung cancer (on basis of microscopy and IHC) used to be adenocarcinoma, squamous cell carcinoma, and small cell carcinoma. Presently, it’s important to subtype lung Adenocarcinoma into EGFR/ ALK/ ROS1 driven. Specific drugs are available to target these mutations and they have proven to be superior to chemotherapy in controlling cancer. These mutations can be detected in tumor biopsy samples by specialized tests like PCR (Polymerase chain reaction), FISH (Fluorescence in-situ hybridization), etc. Detecting such biomarkers has revolutionized the treatment outcomes in advanced lung cancer. In few cases where a biopsy cannot be done (which is the case with few patients), these mutations can be detected in tumor cells that are shed into blood (called circulating tumor DNA / circulating tumor cells) by an advanced test called Liquid biopsy.

Advances happened in the diagnostic realm of hematologic malignancy also. Subtyping of Acute and chronic leukemias is important for accurate treatment. This is possible with a technique called FACS/ Flow cytometry. This has now become a standard test that should be done before embarking on treatment. Further risk stratification of these leukemias and lymphomas are sometimes important and this is achieved with FISH/PCR/ Karyotyping.

These advances in pathology have made it possible to accurately subtype the major types of cancer and have heralded the era of personalized medicine in oncology. Pathology has truly become the Final Diagnosis.

Written by 
Dr. G VeniPrasanna, 
MD., Pathologist, 
Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam.

Tobacco – The Most Common Preventable Cause Of Cancer

Dr. B Rakesh Reddy

Dr. B Rakesh Reddy

During the early days of my training as a medical oncologist at AIIMS, New Delhi, I was alarmed to see patients as young as 20 years being diagnosed with advanced stages of oral cavity cancers and dying within one year of diagnosis despite treatment. Tobacco chewing is the single most important cause of these cancers and in certain parts of the country, it is so prevalent that it has become the most common cause of cancer.

Research points out that Tobacco abuse is the most common cause of cancer. It is responsible for 10 different types of cancers and collectively they are referred to as ‘Tobacco-related cancers’. They are head and neck cancers (mostly related to tobacco chewing), Lung cancer (primarily due to tobacco smoking), esophageal (food pipe) cancer, stomach cancer, pancreatic cancer, kidney cancer, bladder cancer, liver cancer, cervix cancer and acute myeloid leukemia (a type of blood cancer). Together, these account for almost 40% of the cancer burden worldwide, making tobacco the single most common cause of cancer.

Tobacco smoke has at least 70 chemicals that cause cancer, called as carcinogens. Tobacco chewing causes irritation of mucosa in the oral cavity which on long term exposure turns into cancer. An indirect exposure to tobacco smoke from people who smoke around you can place you at a higher risk of getting cancer. This is called ‘passive smoking’ and is especially important to pregnant women as it is shown to be one of the causes of childhood cancers.

If the current trend in smoking and population growth continue, the number of current smokers is expected to reach 2 billion worldwide by 2030. The WHO (World Health Organization) estimates that one out of two young people who start smoking and continue smoking throughout their lives will develop ‘Tobacco-Related Cancer’ (TRC). The numbers are alarming. According to the latest GLOBOCAN data (2018) for India, there were 1.1 million new cases of cancers occurring in a year and 2.2 million people living with cancer. Of these, at least 40% are tobacco-related. Even these reports are likely to be an under-representation due to lack of a good cancer registry covering an adequate population.

What these numbers would suggest is that cancer incidence is growing at an alarming rate and unfortunately a very significant proportion of it is due to a preventable cause, tobacco abuse. The need of the hour is a strong effort from Government and regulatory authorities to curb tobacco. Effective policies, public education through popular media and partnership of all stakeholders across multiple sectors are some of the ways. Every year on 31st May, the WHO and its global partners celebrate World No Tobacco Day (WNTD). The annual campaign is an opportunity to raise awareness on the harmful and deadly effects of tobacco use and second-hand smoke exposure, and to discourage the use of tobacco in any form.

The focus of World No Tobacco Day 2019 is on “tobacco and lung health.” The campaign aims to increase awareness on the negative impact of tobacco on people’s lung health, from cancer to chronic respiratory disease.

The focus is not just on Government and such campaigns but on the public as well to understand the risks. Peers to peers, parents to children should talk about the negative impact of tobacco. Its time to ‘kick the butt’!

#It’sNeverTooLate

Written by
Dr. B. Rakesh Reddy, 
Consultant Medical Oncologist & Hemato-oncologist,
Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam.

All about ‘Head and Neck’ Cancers !

Dr. Praveena Voona

Dr. Praveena Voona

Of the 10 lakh cases of cancer detected in India every year, around 2 lakh are cancers of the ‘head and neck’ category.

‘Head and Neck’ cancers are tumors in and around the throat, larynx, nose, sinuses, or mouth.  These develop when healthy cells in these regions change and grow out of control forming a mass called tumor. They are mostly squamous cell carcinomas, which originate from flat squamous cells that form the surface area of tissue inside head and neck. In India, oral squamous cell carcinoma is the most common cancer in men and the fourth most common cancer in women. Cancers of the lip and oral cavity are the second most common cancer in India.

Head and neck cancer is caused by tobacco use, use of both smoke & smokeless tobacco, and over-consumption of alcohol. Other risk factors include infection with human papilloma virus (HPV) and overexposure to sun-rays.

The symptoms of head and neck cancer include red or white patches on the gums, breathing difficulties, pain while swallowing, lump or sore that doesn’t heal, unexplained change-invoice, fatigue, unexplained weight-loss or pain in the face. Tests such as biopsy, endoscopy, X-ray, CT-scan, Ultrasound,  and PET-CT scan are recommended to diagnose head-and-neck cancer.

The treatment options include surgery, radiotherapy, chemotherapy and a combination of these and depend on the tumor location, cancer stage, person’s age, and general health condition.

Patients with localized(Stage I and II) head and neck carcinomas are generally managed with either surgery or radiation therapy alone. However, a combined modality treatment may be required in cases with high-risk features. In more advanced stages (III, IV A & IV B), the disease is typically managed with both radiotherapy and chemotherapy. Palliative systemic therapy is appropriate for most patients with locally recurrent and metastatic disease.

Newer therapies like Immunotherapy and targeted therapy can be employed that may use body’s own mechanisms to fight cancer. Immunotherapy or targeted therapy is different from traditional chemotherapy in the sense that it works by targeting the cancer-specific genes, proteins, or tissues limiting damage to the healthy cells. It works if the tumor has the necessary target proteins to attack. Immunotherapy boosts the body’s natural defences to fight cancer.

In general, family members and friends often play an important role in taking care of a person with ‘head and neck’ cancer.

Written by
Dr. Praveena Voonna,
Consultant Medical Oncologist,
Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam.

Lower your risk for colorectal cancer

Dr. B Rakesh Reddy

Dr. B Rakesh Reddy

You can prevent CRC by being physically active, eating plenty of fruits and vegetables, and limiting the intake of alcohol.

In colorectal cancer (CRC), there is a malignant growth in the large intestine. In the advanced stages, cancer spreads from the intestine to the liver. Rarely does it spread to the lungs or bones, but when it does, it is known as metastatic CRC.

Globally, CRC is the 3rd most common cancer and the 4th most common cause of death. It is more common in developed countries, but its incidence has also been rising in developing countries. In India, it is the seventh most common form of cancer.

The symptoms are blood in stools, altered bowel habits, anaemia, or unexplained weight loss. The risk factors are advancing age, a family history of colon cancer, a diet high in fat and red meat but low in fibre, smoking, alcohol consumption, obesity, and sedentary lifestyle.

Detection in the early stages maximizes the chances of cure. The screening tests for CRC are fecal occult blood test (FOBT) and colonoscopy.

In the early stages (1 & 2), surgery is the form of treatment, and it is curative in more than 90% of cases. For stage 3 colon cancers, chemotherapy is given for 3-6 months after surgery. For rectal cancers, radiotherapy is also used.

For stage 4 (metastatic) CRC, the primary mode of treatment is chemotherapy. Additionally, targeted therapy significantly helps in improving the life spans of patients. The use of certain ‘biomarkers’ has enabled oncologists to select the appropriate form of targeted therapy. This is referred to as ‘personalization of treatment’.

With the advances in treatment and the advent of immunotherapy, the life span of a stage 4 CRC patient has gone up by 3 years.

You can prevent CRC by being physically active, eating plenty of fruits and vegetables, limiting the intake of fast food and alcohol, and exercising regularly.

#It’sNeverTooLate

Written by
Dr. B. Rakesh Reddy, 
Consultant Medical Oncologist & Hemato-oncologist,
Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam.