Challenging the Conventions in Cancer

On World Cancer Day but I thought I will share a few ‘contrarian’ thoughts :

Facts :

  1. Cancer incidence is rising
  2. We are not making great headway in management of cancer so overall cancer mortality remains nearly static inspite of trillion dollar spend
  3. We have to discard the current conventions and adopt a different approach

On the basis of this, l challenge some conventional concepts to start thinking for alternate strategies.

1) Bigger surgery is NOT better. 

This is a concept which has been challenged, thanks to surgeons who were keen observers who collaborated with their pathology colleagues and came to the conclusion that removing large chunks of tissue around the tumour would not be necessary. This led to less mutilating surgery.  Classic example being breast surgery in which William Halsted, the pioneer, proposed the Radical Mastectomy with removal of muscles.  Even without the modern chemotherapy or radiation therapy came the modifications involving less

aggressive surgeries.  Yes, there was a time  ultra radical surgeries were done but soon surgeons realised that it is unnecessary mutilation and resorted to more organ preservation techniques.  The same thing also happened in rectal  cancer surgery, where without having a permanent bag or colostomy, normal on using basic common sense and good pathology normal passage could be restored.

2) Population screening is NOT necessary – mass screenings is not an answer for early diagnosis because there is no way a population based screening can be done in a country of 1.2 billion people and this will lead to a lot more false positive results and lead to a panic amongst people.  Then, is there any answer for this?  I would again urge a selective screening.  It doesn’t matter if a mammography detects a breast lump or a woman detects a breast lump after a little while at a 1 cm. or 1.5 cm. site.  It is not a late detection. Likewise many of the tumours can be detected early if only we are aware of our body.  That is the fundamental approach.  We should be aware of our body and any change to be noticed and medical attention sought.

Selective screening is the mantra

3) Randomized trials in drug treatment  are NOT way forward

     This is the biggest hurdle for progress and also it is the most expensive part.  Do you know that 90% of the randomized trials are neither   conclusive  nor have been completed particularly if you comparing Drug A with Drug B. It is a total waste of resources and giving a false hope to patient recruited.  Drug companies spend millions of dollars on trials and obviously the cost of drugs, get passed on to the hapless patients.

4) Targeted therapy is NOT a miracle 

      Targeted therapy in  limited instances has been helpful, rest of the time it has proven to be of marginal benefit and extremely expensive and also many times, toxic.  So, chasing these targeted agents is the biggest myth. the intelligence of a cancer cell is far superior that that of a drug company and it immediately changes into different pathways which no longer are inhibited by the expensive chemotherapy drugs.  So let us stop  this chasing these targeted agents and stop doing these trials which have marginal benefits.

5) Genetic testing for every cancer is NOT necessary

The full page ads on gene testing is marketing gimmick without a scientific basis. I have not come across a single patient benefited by so called personalised treatment as the number of active drugs same few whatever the profile may say. The long reports have no value in practice.

Now that brings us to the big question – Do we spend the money on advanced cancers with diminishing returns or early cancers.  Answer to this is obviously early cancers. 

So stop investing funds on chemotherapy and targeted therapy.  It is much better if we can only develop diagnostic techniques which are less invasive or non invasive which will detect cancers which are not symptomatic and that will be the biggest shift to bring us closer to reducing mortality in cancer. 

As long as there is civilization, cancer will exist.  The only thing we can do is reduce the deaths from cancer. 

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A selfie that can save you

Mr. Brahma Rao, a bank executive noticed a small ulceration on the border of his tongue. He was not a smoker and never chewed tobacco. He thought perhaps she has injured his tongue by teeth bite and continued with normal activities. After nearly 4 months he suddenly noticed severe pain in his right ear which alarmed him and the ulcer also had increased in size. He was worried and contacted me. As he was abroad and visiting his family and was due to return, I asked him to send me the pic of the border of the tongue like ‘a selfie of the tongue’ which he did.

tongue-pic

It clearly showed a small 1 cm. ulcer and the edges were elevated. It is a very important symptom and sign as lesions on the tongue having what is called ‘referred pain ‘ of the ear is because of nerve infiltration. I diagnosed him as early tongue cancer and he underwent treatment. Fortunately there was no spread at all and he recovered very well.

 

It is an important pointer for all. The tongue is so visible and can be easily seen and felt. Any kind of nodule or ulcer or nodule that is persistent for more than a month is not to be taken lightly. Tongue cancer is painless and has referred pain to the ear. In vitamin deficiency or an aphthous ulcer is more painful, superficial and small.

It is easy to document by a pic and sent to a doctor.

Ultimately you are responsible for your own health and sooner the diagnosis, the safer you will be.

Can anyone ‘sense’ cancer?

Can anyone feel that they may have a serious illness and it could be cancer?

You may think ‘Its not possible’, but yes cancer can be ‘sensed’

I ask all the patients, whether they felt ‘not normal’ and that there is a serious illness lurking around. Most of them say  ‘yes’. There is a feeling that something is wrong. the body is becoming weaker and the energy is going down. Or loss of weight and stamina.Many times visit to doctor is postponed or get treated with some usual medications.

Its a combination of nonspecific symptoms, but one does feel ” definitely unwell” .

I am reading the book” when breath becomes air” by a young neurosurgeon Paul Kalanithi, who is diagnosed with advanced lung cancer. He also realises that there is some serious illness, may be ‘cancer’. Its a moving story of an aspiring surgeon who works hard and is about to realize his dreams, when cancer strikes him. He writes his own story , perhaps mirroring the stories of many patients he had seen.

I recall a professor of surgery, a well known teacher, who one day suddenly declared that he had pancreatic cancer. His family and friends were surprised as he looked healthy.

‘Why  do you think so?’

‘For years I have taught students that migratory phlebitis  (red streaks on legs ) is a sign of pancreatic cancer and I have show them in my patients’.

“Now I have the same sign”.

He was investigated in disbelief, but the diagnosis was confirmed.

The first response however is denial, even more amongst doctors. No it cannot be. Then as time goes, the inevitable symptoms like pain set in and  the diagnostic tests are done.

I see many like him. So many experience that loss of energy as though slowly the life is getting squeezed. Its is best to  get investigated at the suspicion and not wait for full blown symptoms. Time indeed is the most critical as stage of diagnosis is the only major predictor of prognosis. Earlier the better.

You may be a busy corporate executive or your children have board exams. Something is always happening, but your health is a super priority. Nothing else matters.

The same thing happens to Paul in the novel. Loss of weight is due to ‘overwork’. Acidity is ascribed to ‘too many coffees and  stress’. Not eating well as ‘no time’.

I recently saw a CEO with symptoms and its only after six months that he went for investigations. Work deadlines,travel, annual reports , social life – so many ‘important’ things- more important than our health. we have so many proverbs but hardly ever care.

Health is wealth ( proverbial sense) , but it only ‘depreciates’ and not ‘appreciate’ like real ‘wealth’ in the bank.

Well the bank balances can evaporate with a single illness.

I see this also in elderly. ‘why bother my son or daughter when they are so busy with their jobs’. That’s not correct. Most families care for their parents and would be devastated if they find an advanced cancer . Many just ask the question” Can my mother or father be cured?”. No matter how old, even 80s, but they want the parents to be with them a bit longer.

Thats normal and human, just push the line a bit. A little more time , just a little !

So when you sense ‘something is wrong’, don’t brush it away.

An early check up can save your precious life.

 

 

 

 

Is there ‘Super Test’ for Cancer? How about a PET scan ?

Madhuri’s mother was diagnosed with Colon cancer when she started passing blood in the stool and her hemoglobin fell to 8 gms. She then underwent investigations and was diagnosed; following which she came to me for surgery. Obviously there was immense panic in the family. Immediately Madhuri, her brother and sister asked me frantically if there is a ‘super test’ for cancer. A single test to say whether cancer is present or NOT. Then the whole family can get the test done !

There has always been a demand from the public, along with determined efforts from the research community to find a single blood test that can identify cancer. In the last couple of decades, there have been many false starts and false hopes;

The first set of blood-tests were called ‘tumour markers’, which are proteins circulated from the tumour cells. CEA was one such marker which was identified in colon cancer patients. The immediate expectation was “Oh! Yes” there is a blood test that can identify colon cancer. However, as people started getting checked for CEA it was found that CEA was not only high in colon cancer but also in colitis, in smokers and in many other non-malignant situations including cirrhosis of the liver.

This is the fundamental truth about cancer. As the cancer cell is very similar to normal cells, the protein secreted or discharged from cancer cells are also similar to those from the normal cells. Most of the screening tests lack the specificity expected out of such investigation.

The second important push for cancer diagnosis has been ‘imaging’, for example; Abdominal CT scans. Its an important investigation to detect a tumour, but is not recommended as a routine test just to reduce your anxiety.

The most frequently ill-advised investigation is the PET Scan. Unfortunately it’s being prescribed by family physicians – “When anyone is anxious about a cancer, Get a PET scan done “. Recently we went to a shop and the owner came to know that I am an oncosurgeon. His first question was, “How frequently should I get a PET scan done?”.

A PET Scan is based on the principle that the tumour cells uptake and metabolize glucose of the normal cell. But again there are many fallacies; (1) it should only be used for staging for cancer and not screening normal population (2) it should never be used to satisfy anxiety of relative diagnosed with cancer. There are many false positives like a simple infection can lead to increased glucose uptake of cells and show positive on PET Scan.

Recently a patient came and said “My brain is affected”. I asked ‘Why”? he said “It shows in the PET Scan”.   Obviously it will be shown because brain is one of the most metabolically active organ. Any investigation needs to be done after careful thought and then also interpreted in the context of ordering and not randomly.

In short, there is no single test that can be used in the community to detect cancer. Once again I go back to the same advice – Be aware of the symptoms and then get appropriate investigations. ‘Seven warning signals’ , Caution and Action ( see earlier blog) are the best bet we have for early detection.

Does Biopsy In Cancer lead to its spread ?

 

Anish, is a senior engineer in a private sector power company. His mother was recently suspected as having cancer of the gall bladder.  CT Scan was suggestive of malignancy but not 100% certain.

  For any cancer, it is important to have a biopsy and a confirmation of the diagnosis, to have a look at the tissue under a microscope and to make a pathological diagnosis.  This is the final proof that it is malignancy.  So many times benign conditions mimic malignancy and it is really not appropriate to treat any patient as cancer unless it is confirmed 100%.  So I had suggested a biopsy to Anish.  He  was ‘terrified’ and said, “No doctor, if biopsy is done, I believe that cancer is likely to spread faster”. 

This is a complete myth. A biopsy will never lead to spread of cancer.  Perhaps the reason for this myth is that many times the patients undergo what’s called exploratory surgery or laparotomy after the diagnosis of malignancy in which  we may find that the disease is advanced much more than even the CT Scan has shown.  In such situations, the surgeons are forced to abandon the surgery  and obviously the patient would deteriorate.  It has nothing to do with the surgery or the biopsy.  It is just a progression of the disease. 

That brings us to the question – are there situations where we do not need a biopsy?  The answer to that is Yes.  In some critical areas when some other tests are completely collaborative, we may not need a biopsy and sometimes we may not be able to get a biopsy because of the location of the lesion.  In such situations we are justified in planning treatment without a biopsy.  In most of the situations biopsy is also important because as I said earlier, cancer is not a single disease, there are many different types of cancers that need different treatment.  Similar to ‘Fever’, which is not a diagnosis eg. typhoid would be treated differently from malaria.  Likewise cancer is not a diagnosis, histological type is definitely important.  Some of the types of cancers respond dramatically to drug treatment and radiation, they do not need surgery.  So it is important for the cancer specialist to identify the type of cancer.

So Anish had to be convinced that Biopsy had to be done for his mother and as she was lucky that it was not a cancer and could undergo a surgery for removal of gall bladder.

Dont be scared if the doctor suggests a biopsy. It will make a difference and is essential.