Category: oncosurgeries

What is colorectal cancer?

Colorectal cancer is a term used to refer to cancer that starts in the colon or rectum. Colon and rectal cancers begin in the digestive system, also called the GI (gastrointestinal) system. This is where food is processed to create energy and rid the body of waste matter.

After food is chewed and swallowed, it travels down to the stomach. There it is partly broken down and sent to the small intestine. The word “small” refers to the diameter of the small intestine. The small intestine is really the longest segment of the digestive system. It is about 20 feet long.

The small intestine continues breaking down the food and absorbs most of the nutrients. The small intestine joins the large intestine (large bowel), a muscular tube about five feet long. The first part of the large bowel, called the colon, absorbs water and nutrients from the food and also serves as a storage place for waste matter. The waste matter moves from the colon into the rectum, the final 6 inches of the large bowel. From there the waste passes out of the body through the opening called the anus during a bowel movement.

The colon has 4 sections:

Ascending colon

Transverse colon

Descending colon

Sigmoid colon

Cancer can start in any of the four sections or in the rectum. The wall of each of these sections (and rectum) has several layers of tissues. Cancer starts in the inner layer and can grow through some or all of the other layers. Knowing a little about these layers is helpful because the stage (extent of spread) of a cancer depends to a great degree on which of these layers it affects.

Cancer that starts in the different areas may cause different symptoms. In most cases, colon and rectum cancers develop slowly over a period of several years. We now know that most of these cancers begin as a polyp – a growth of tissue into the center of the colon or rectum. A type of polyp known as adenomacan canbecome cancerous. Removing the polyp early may prevent it from becoming cancer.

Over 95% of colon and rectal cancers are adenocarcinomas. These are cancers of the cells that line the inside of the colon and rectum. There are some other, more rare, types of tumors of the colon and rectum, but the facts given here refer only to adenocarcinomas.

What causes colorectal cancer?

While we do not know the exact cause of most colorectal cancer, there are certain known risk factors. A risk factor is something that increases a person’s chance of getting a disease. Some risk factors, like smoking, can be controlled. Others, such as a person’s age, can’t be changed. Researchers have found several risk factors that increase a person’s chance of getting colorectal cancer.

What are the risk factors for Colorectal Cancer?

Age: Your chance of having colorectal cancer goes up after age 50. More than 9 out of 10 people found to have colorectal cancer are older than 50.

Having had colorectal cancer before: Even if a colorectal cancer has been completely removed, new cancers could start in other areas of your colon and rectum.

Having a history of polyps: Some types of polyps increase the risk of colorectal cancer, especially if they are large or if there are many of them.

Having a history of bowel disease: Two diseases called ulcerative colitis and Crohn’s disease increase the risk of colon cancer. In these diseases, the colon is inflamed over a long period of time and there may be ulcers in its lining. If you have either of these, you should start being tested at a young age and have the tests often.

Family history of colorectal cancer: If you have close relatives who have had this cancer, your risk is increased. This is especially true if the family member got the cancer before age 60. People with a family history of colorectal cancer should talk to their doctors about how often to have screening tests.

Certain family syndromes: A syndrome is a group of symptoms. For example, in some families, members tend to get a type of syndrome that involves having hundreds of polyps in their colon or rectum. Cancer often develops in one or more of these polyps.

If your doctor tells you that you have a condition that makes you or your family members more likely to get colorectal cancer, you will probably need to begin colon cancer testing at a younger age and you might think about genetic counselling.

Ethnic background: Jews of Eastern European descent (Ashkenazi Jews) have a higher rate of colon cancer

Diet: A diet high in fat, especially fat from animal sources, can increase the risk of colorectal cancer

Lack of exercise: People who are not active have a higher risk of colorectal cancer

Smoking: Most people know that smoking causes lung cancer, but recent studies show that smokers are 30% to 40% more likely than non smokers to die of colorectal cancer. And smoking increases the risk of many other cancers as well.
Alcohol: Heavy use of alcohol has been linked to colorectal cance.

How is colorectal cancer found?

Screening tests are used to look for disease in people who do not have any symptoms. In many cases, these tests can find colorectal cancers at an early stage and greatly improve the chances of successful treatment. Screening tests can also help prevent some cancers by allowing doctors to find and remove polyps that might become cancer. There are several tests used for colorectal cancer:

Stool blood test (fecal occult blood test – FOBT):

This test is used to find small amounts of hidden (occult) blood in the stool. A sample of stool is tested for traces of blood.

A newer kind of stool blood test is known as FIT (faecal immunochemical test). It is very much like the FOBT but is perhaps a little easier to do and it gives a fewer number of false positive results.

Flexible sigmoidoscopy (flex-sig):

A sigmoidoscope is a slender, lighted tube about the thickness of a finger. It is placed into the lower part of the colon through the rectum. This allows the doctor to look at the inside of the rectum and part of the colon for cancer or polyps. Because the tube is only about 2 feet long, the doctor is only able to see about half of the colon. The test can be uncomfortable but it should not be painful. Before the test, you will need to take an enema to clean out the lower colon.

Colonoscopy:

A colonoscope is a longer version of the sigmoidoscope. It allows the doctor to see the entire colon. If a polyp is found, the doctor may remove it. If anything else looks abnormal, a biopsy might be done.

To do this, a small piece of tissue is taken out through the colonoscope. The tissue is sent to the lab to see if cancer cells are present. This test can be uncomfortable. To avoid this, you will be given medicine through a vein to make you feel relaxed and sleepy.

Barium enema with air contrast:

A chalky substance is used to partly fill and open up the colon. Air is then pumped in to cause the colon to expand. This allows good x-ray films to be taken. You will need to use laxatives the night before the exam and have an enema the morning of the exam.

Virtual colonoscopy:

You might think of this as a super x-ray of the colon. Air is pumped into the colon to cause it to expand, and then a special CT scan is done. Right now, this test is not among those recommended by the ACS or other major medical organizations for finding colon cancer early. More studies are needed to find out if it is as good as or better than other methods of finding colon cancer early.

What are the symptoms of colorectal cancer?

Most people with early colon cancer don’t have symptoms. Symptoms usually appear with more advanced disease. If something suspicious turns up as a result of screening or if you have symptoms, you will need further tests. Symptoms of colorectal cancer include:

A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days

A feeling that you need to have a bowel movement that doesn’t go away after doing so

Bleeding from the rectum or blood in the stool (often, though, the stool will look normal)

Cramping or steady stomach pain

Weakness and tiredness

Just because you have these symptoms does not mean you have cancer. But you need to talk to your doctor to be sure. It is also possible to have colon cancer and not have any symptoms.

How do you diagnose colorectal cancer?

If there is any reason to suspect colon or rectal cancer, the doctor will ask you questions about your symptoms and risk factors (take a medical history) and do a physical exam. Then, you will need to have further tests to find out if the disease is really present, and if so, to see how far it has spread. Some of these tests are the same ones that are used for screening people who do not have symptoms.

Blood tests:

Your doctor will order a blood count to see if you have too few red blood cells (anemia). People with colorectal cancer often become anemic because of bleeding from the tumor.

You might also have blood tests to check your liver function because colorectal cancer can spread to the liver causing problems. There are other substances (tumor markers) in the blood that can help tell how well treatment is working. But these tumor markers are not used to find cancer in people who have not had cancer and who appear to be healthy; rather, they are most often used for follow-up of people who have already been treated for colorectal cancer.

Biopsy: In a biopsy, the doctor removes a small piece of tissue. The tissue is sent to the lab where it is looked at under a microscope to see if cancer is present.

Ultrasound: Ultrasound uses sound waves to produce a picture of the inside of the body.

CT Scan (computed tomography): A CT scan uses x-rays to take many pictures of the body that are then combined by a computer to give a detailed picture. A CT scan can often show whether the cancer has spread to the liver, lungs, or other organs. CT scans can also be used to help guide a biopsy needle into a tumor.

A new way to use a CT scan is to do a virtual colonoscopy. After stool is cleaned from the colon and the colon is filled with air, a computer can put together a picture of the inside of the colon. This method requires the same preparation as for a colonoscopy and there is some discomfort from the bowel being filled with air. If anything not normal is seen, a follow-up colonoscopy will be needed.

MRI (magnetic resonance imaging):

Like CT scans, MRI displays a cross-section of the body. However, MRI uses radio waves and strong magnets instead of radiation. As with CT scans, a contrast dye may be injected, although this is used less often. MRI scans are helpful in looking at the brain and spinal cord. They take longer than CT scans and you may have to be placed inside a tube. This can feel confining and upset people with a fear of closed spaces.

Chest x-ray:

This test may be done to see whether colorectal cancer has spread to the lungs.

PET scan (positron emission tomography):

In this test, a type of radioactive sugar is used. The cancer cells absorb high amounts of the sugar. PET is useful when your doctor thinks the cancer has spread, but doesn’t know where. PET scans are now more accurate because they can be combined with a CT scan.

Angiography:

For this test, a tube is placed into a blood vessel and moved until it reaches the area to be studied. Then a dye is injected and a series of x-ray pictures is taken. When the pictures are complete, the tube is removed. Surgeons sometimes use this method to find blood vessels next to cancer that has spread to the liver. The cancer can then be removed without causing a lot of bleeding.

Staging of colorectal cancers

Staging is the process of finding out how far the cancer has spread. This is very important because your treatment and the outlook for your recovery depend on the stage of your cancer. For early cancer, surgery may be all that is needed. For more advanced cancer, other treatments such as chemotherapy or radiation therapy may be used.

There is more than one system for staging colon or rectal cancer. Some use numbers and others use letters. But all systems describe the spread of the cancer through the layers of the wall of the colon or rectum. They also take into account whether the cancer has spread to nearby organs or to organs farther away.

Stages are often labelled using Roman numerals I through IV (1-4). In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

The other tool that doctors use to describe the stage is the TNM system.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How deeply has the primary (first) tumor penetrated the bowel lining? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

For most people, the stage is not known until after surgery, so your doctor may wait until then to assign a number. This will help you both decide on the best treatment for you.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: Refers to cancer in situ. The cancer cells are only in the mucosa (the inner lining) of the colon or rectum. Most colorectal cancers at this stage can be treated by polypectomy (removal of the mass of tissue that develops on the inside wall).

Stage I: The cancer has grown through the mucosa and has invaded the muscular layer of the colon or rectum. It has not spread into nearby tissue or lymph nodes (T1 or T2, N0, M0).

Stage IIA: The cancer has grown through the wall of the colon or rectum and has not spread to nearby tissue or to the nearby lymph nodes (T3, N0, M0).

Stage IIB: The cancer has grown through the layers of the muscle to involve the lining of the abdomen (visceral peritoneum). It has not spread to the nearby lymph nodes or elsewhere (T4a, N0, M0).

Stage IIC:The tumor has spread through the wall of the colon or rectum and has invaded neighboring structures. It has not spread to the nearby lymph nodes or elsewhere (T4b, N0, M0).

Stage IIIA: The cancer has grown through the inner lining or into the muscle layers of the intestine and spread to one to three lymph nodes, or to a nodule of tumor in tissues around the colon or rectum that do not appear to be lymph nodes but has not spread to other parts of the body (T1 or T2, N1 or N1c, M0; or T1, N2a, M0).

Stage IIIB: The cancer has grown through the bowel wall or to surrounding organs and into one to three lymph nodes or to a nodule of tumor in tissues around the colon or rectum that do not appear to be lymph nodes but has not spread to other parts of the body (T3 or T4a, N1 or N1c, M0; T2 or T3, N2a, M0; or T1 or T2, N2b, M0).

Stage IIIC: The cancer, regardless of the depth of invasion in the wall of the colon, has spread to four or more lymph nodes, but not to other distant parts of the body (T4a, N2a, M0; T3 or T4a, N2b, M0; or T4b, N1 or N2, M0).

Stage IVA: The cancer has metastasized to a single distant part of the body, such as the liver or lungs (any T, any N, M1a).

Stage IVB: The cancer has metastasized to multiple parts of the body (any T, any N, M1b).

Recurrent: Recurrent cancer is cancer that has come back after treatment

What is the treatment for colorectal cancer?

The treatment of colorectal cancer depends on the size and location of the tumor, whether the cancer has spread, and the person’s overall health.

Treatment based on cancer staging

The usual treatment of stage 0 cancer in situ is a simple polypectomy during a colonoscopy. There is no additional surgery unless the polyp is unable to be fully removed by polypectomy.

If the cancer is stage I, surgical removal of the tumor and lymph nodes is usually the only treatment necessary.

Patients with stage II colon cancer, which involves deeper penetration of the bowel lining without involving the regional lymph nodes, are treated with surgery and some patients are treated with adjuvant chemotherapy.. However, cure rates for surgery alone are quite good, and the benefits of additional treatment are still uncertain for people with this stage of colon cancer.

If the cancer is stage III and has spread to nearby lymph nodes, the treatment usually involves surgical removal of the tumor followed by adjuvant chemotherapy

For patients with stage II or III rectal cancer, radiation therapy is usually offered in combination with chemotherapy, either before or after surgery.

At stage IV, it is usually not recommended that patients have surgery to remove the primary tumor in the colon, unless the tumor is causing physical problems, such as bleeding or blocking the intestines. Standard treatment includes chemotherapy along with a targeted treatment. If possible, surgery to remove metastases (areas where cancer has spread) may also be done. Generally, such surgery is possible if there are a limited number of spots to where the tumor has spread.

Surgery

The most common treatment for colorectal cancer is surgery to remove the tumor, called surgical resection. Part of the healthy colon or rectum and nearby lymph nodes will also be removed.

Some patients may be able to undergo laparoscopic colorectal cancer surgery. With this technique, several viewing scopes are passed into the abdomen while a patient is under anesthesia. The incisions are smaller and the recovery time is often shorter than with standard colon surgery. Laparoscopic surgery is as effective as conventional colon surgery in removing the cancer. Surgeons who perform laparoscopic surgery have been specially trained in that technique.

Less often, a person with rectal cancer may need to have a colostomy. This is a surgical opening, or stoma, through which the colon is connected to the abdominal surface to provide a pathway for waste to exit the body; such waste is collected in a pouch worn by the patient. Sometimes, the colostomy is only temporary to allow the rectum to heal, but it may be permanent. With modern surgical techniques and the use of radiation therapy and chemotherapy before surgery, most people treated for rectal cancer do not require a permanent colostomy.

Some patients may be candidates for surgery on the liver or lungs to remove tumors that have spread to those organs. An alternative is to use radiofrequency ablation (RFA; energy in the form of radiofrequency waves to heat the tumors). Not all liver or lung tumors can be treated with this approach. In some cases, RFA can be done through the skin. In other cases, RFA can be done during surgery. While this can allow preservation of liver and lung tissue that might be removed in a regular surgical resection, there is also a chance that some portions of the tumor will not be destroyed using this technique.

In general, the side effects of surgery include pain and tenderness in the area of the operation. The operation may also cause constipation or diarrhea, which usually goes away after a while. People who receive a colostomy may have irritation around the stoma. The doctor, nurse, or a specialist in colostomy management (called an enterostomal therapist) can teach the patient how to clean the area and prevent infection.

Many people require retraining of the bowel after surgery; this may require some time and assistance. People should talk with their doctor if they do not regain good control of bowel function.

Radiation therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells and is commonly used for treating rectal cancer because this tumor tends to recur locally.

A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a specific time.

External-beam radiation therapy uses a machine to deliver x-rays to the site of the body where the cancer is located. Radiation treatment is given five days a week for several weeks and may be given in the doctor’s office or at the hospital.

In some cases, specialized radiation therapy techniques, such as intraoperative radiation therapy (a high, single dose of radiation therapy given during surgery) or brachytherapy (placing radioactive “seeds” inside the body), may help eliminate small areas of tumor that could not be removed during surgery.

For rectal cancer, radiation therapy may be used before surgery (called neoadjuvant therapy) to shrink the tumor so that it is easier to remove or after surgery to destroy any remaining cancer cells, as both have shown value in treating this disease

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. It may also cause bloody stools (bleeding through the rectum) or bowel obstruction. Most side effects go away soon after treatment is finished.

Sexual problems, as well as infertility (the inability to have a child) in both men and women, may occur after radiation therapy to the pelvis.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells.

Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time. Chemotherapy for colorectal cancer is usually injected directly into a vein, although some chemotherapy can be given as a pill.

Chemotherapy may be given after surgery to eliminate any remaining cancer cells. In some situations, for rectal cancer, a doctor will give chemotherapy and radiation therapy before surgery to reduce the size of a rectal tumor and lower the chance of cancer returning.

Targeted therapy

Targeted therapy is a treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. These drugs are becoming more important in the treatment of colorectal cancer.

What is pancreas?

The pancreas is a pear-shaped gland located in the abdomen between the stomach and the spine. It is about six inches in length and is made up of two major components:

The exocrine component, made up of ducts and acini (small sacs on the end of the ducts), makes enzymes (specialized proteins) that are released into the small intestine to help the body digest and break down food, particularly fats.

The endocrine component of the pancreas is made up of specialized cells lumped together in islands in the organ, called islets of Langerhans. These cells make specific hormones, most importantly insulin, the substance that helps control the amount of sugar in the blood.

How does cancer affect pancreas?

Two types of cancer can affect the pancreas:

The pancreas has three main parts: the head (which is the part closest to the duodenum and the common bile duct), the body (the middle portion), and the tail. Cancer can develop in any of these parts.

The most common, cancer of the exocrine pancreas (hereafter referred to as pancreatic cancer), originates in the pancreatic ducts. The ducts are responsible for carrying pancreatic juice to the intestines. This type of pancreatic cancer is discussed below.

Another type of cancer consists of a group of tumours that originate from the cells that make hormones such as insulin. Like pancreatic juice, these hormones are made by the pancreas, but instead of traveling through the pancreatic ducts, they are secreted directly into the blood. These tumous are collectively referred to as pancreatic endocrine tumors, and are not addressed here. They are also very rare.

What are the risk factors?

A number of factors increase the risk of developing pancreatic cancer including

smoking

chronic pancreatitis (chronic inflammation of the pancreas)

and possibly diabetes mellitus.

What are the signs and symptoms of pancreatic cancer?

Most patients with pancreatic cancer experience pain, weight loss, and/or jaundice (yellowing of the skin).

Pain is common, and is usually felt in the upper abdomen as a dull ache that radiates to the back. It may be intermittent (comes and goes) and it may be worsened by eating.

Weight loss can be profound. Some people lose weight because of loss of appetite, the sensation of felling full after eating only a small amount of food, or diarrhoea. If the pancreatic duct is blocked by the cancer and the pancreatic juice cannot enter the intestines, the stools may seem greasy and tend to float in the toilet bowl because they contain undigested fat.

Jaundice is a sign of high levels of bilirubin (the main component of bile) in the blood. People with jaundice have yellow skin, whites of the eyes, and urine. A build-up of bilirubin in the blood can be caused by cancers in and around the pancreas, which block the ducts that drain bile from the liver into the intestines. As a result, bowel movements may not be a normal brown colour, and instead have a greyish appearance, described as clay-coloured stools.

Symptoms vary depending upon where the pancreatic cancer is located.

Cancers that develop in the head of the pancreas tend to block the drainage of bile from the liver to the intestines, and typically cause jaundice.

In contrast, tumours that arise in the body or tail are less likely to cause jaundice, and more often cause abdominal pain, weight loss, and diarrhoea.

How do you diagnose this cancer?

If a patient’s signs and symptoms suggest the possibility of pancreatic cancer, a number of different tests can be done to help pinpoint the diagnosis. All tests are not needed in every patient.

Ultrasound of the abdomen

Patients with jaundice will typically have an ultrasound as a first step in the diagnostic process. An ultrasound uses sound waves that are transmitted through a wand-like instrument (a transducer) that applied to the abdomen. The purpose of this ultrasound is to determine whether the bile system is blocked, and to identify where the blockage appears to be located.

CT scan

A CT scan uses x-rays and a computer to take detailed cross sectional pictures of the body, and it may be the initial test ordered in patients who have abdominal pain or unexplained weight loss, particularly if the person is not jaundiced. CT scan may reveal a blockage of the bile and/or pancreatic ducts, a mass within the pancreas or in the periampullary area (where the bile duct, pancreas, and duodenum come together), and/or evidence of cancer spread beyond the pancreas (for example, to the liver).

An injection of dye is usually given during the CT to allow the blood vessels surrounding the pancreas to be studied. The nature and extent of blood vessel involvement helps the surgeon to decide whether or not an operation should be performed.

Endoscopic retrograde cholangiopancreatography(ERCP)

ERCP is a dye study that may be used to outline the pancreatic duct system and bile duct system. It is performed by a gastroenterologist by inserting a small tube (called an endoscope) through the esophagus into the stomach, and then threading it through the duodenum to the papilla of Vater. Dye is then injected through the endoscope into the bile and pancreatic ducts.

The ERCP may help to pinpoint the cause of jaundice, but is usually used only if less invasive tests do not provide enough information. An additional benefit of the ERCP is that if a blockage is identified in one of the bile ducts, it may be possible to place a flexible tube or catheter (also called a “stent”) through the area that is blocked. This procedure can relieve the bile duct obstruction, allowing the bile to once again flow into the intestines, and lowering the amount of bilirubin in the blood operation

Percutaneous transhepatic cholangiopancreatography(PTC)

PTC is an alternative way of visualizing the bile ducts to determine where a blockage is located. Instead of threading a tube into the bile system via the esophagus, a specially trained radiologist threads a tube into the bile ducts by inserting a needle into the liver from outside of the body, and then threading a catheter (over the needle) into the hepatic ducts.

Magnetic resonance cholangiopancreatography (MRCP)

MRCP is an MRI focusing on the bile ducts and pancreas. MRI uses magnetic fields and radio waves to produce detailed pictures of the body. It can create a very detailed three dimensional image of the pancreas, biliary ducts, liver, and surrounding blood vessels without the need for injection of dye.

MRCP is sometimes done if an ERCP or PTC is not technically possible, or if the information provided by the ERCP and CT is incomplete and/or confusing.

Endoscopic ultrasound (EUS)

In this test, ultrasound is done from inside the body by placing the ultrasound transducer on the tip of an endoscope which is then passed into the duodenum by going down the esophagus. EUS is sometimes done if a small tumour is suspected, or to get more information about whether a pancreatic tumor can be removed by surgery.

Biopsy

A biopsy refers to the surgical removal of a small piece of tissue for examination under a microscope, looking for evidence of cancer. For patients suspected of having pancreatic cancer, a biopsy can be performed by inserting a biopsy needle into the area of abnormality. The needle can be inserted into a pancreatic tumor through the skin of the abdominal wall under guidance of a CT scan, or as part of an EUS procedure.

Pancreatic cancer staging

Treatment and prognosis for individual cancers depends upon the extent or “stage” of disease. The most commonly used pancreatic cancer staging system is the TNM (“Tumor, nodes, metastases”) system. It is based upon tumour size and how far the cancer has penetrated into the structures surrounding the pancreas, whether the cancer involves lymph nodes adjacent to the pancreas, and whether the cancer has spread to other organs.

These factors are then combined to assign a “stage grouping” from I to IV, with stage I cancers being the earliest and least advanced stage disease and stage IV the most advanced. The final staging of a pancreatic cancer often depends upon the findings during surgery.

How do you treat this cancer?

Several approaches to treatment of pancreatic cancer are available.

For patients whose cancer has not spread significantly and who are strong enough to withstand an operation, doctors will attempt to remove the cancer surgically. Surgery provides the only opportunity for cure. Surgery is not possible in many patients because the disease is often advanced at the time of diagnosis. Only 5 – 10% of pancreatic cancers are suitable for surgery. Many are not because the cancer has either spread to other organs, or cannot be removed because it is lying too close to, or invading a major blood vessel.

In some cases, chemotherapy and/or radiation therapy will be recommended following surgery while in others it may be offered before surgery (termed neoadjuvant therapy). For patients who are not candidates for surgery, radiation and/or chemotherapy may be offered.

Surgical treatment for pancreatic cancer:

Surgery for tumors in the head of the pancreas

The standard operation for tumours located in the head of the pancreas is a Whipple’s procedure (a pancreaticoduodenectomy). In this procedure, the surgeon removes the pancreatic head, the duodenum (first part of the small intestine), part of the jejunum (the next part of the small intestine), the common bile duct, the gallbladder, and part of the stomach.

The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply (the gastroduodenal artery). These arteries run through the head of the pancreas, so that both organs must be removed if the single blood supply is severed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum, resulting in tissue necrosis.

Pancreaticoduodenectomy (Whipple,sprocedure)

Reconstruction surgery.

In the past, complications and deaths following this operation were high, and cure rates were less than 10 percent. However, more recent results suggest better outcomes:

In experienced hands, the death rate following surgery is less than 4 percent.
The long-term outlook for patients undergoing this surgery varies, depending in part on whether the cancer has affected the lymph nodes. Between 10 and 30 percent of patients undergoing a Whipple’s procedure for pancreatic cancer will be alive and cancer-free five years after the operation.
Surgery for tumours in the body or tail of the pancreas

Because tumours in the body or tail of the pancreas do not cause the same symptoms as those in the head of the pancreas, these cancers tend to be discovered at a later stage, when they are more advanced.

If the patient has a tumour that can be removed surgically, a laparoscopic exploration is usually done first to make sure the cancer has not spread within the abdominal cavity. If surgery is still an option, part of the pancreas is removed, usually along with the spleen. However, long-term outcome for these patients is usually poor.

Adjuvant therapy after surgery

Adjuvant (additional) therapy refers to chemotherapy,radiation, or a combination of both that is recommended for patients who are thought to be at high risk of having cancer reappear (termed a recurrence or a relapse) after a tumour has been removed surgically. Even if the tumour has been completely removed, tiny cancer cells may remain in the body and grow, causing relapse after surgery. For such patients, adjuvant therapy can prevent relapse and prolong survival by eradicating the tiny cancer cells before they have had a chance to grow.

Treatment of locally advanced pancreatic cancer

Locally advanced pancreatic cancer has not yet spread to distant locations in the body, but has extended into surrounding organs or structures, making surgical removal impossible. The best therapy for locally advanced pancreatic cancer is unknown. Options include chemotherapy alone or a combination of radiation therapy with chemotherapy. This approach increases the average survival for patients with locally advanced cancer by about one year compared to no treatment, but rarely results in long-term survival.

CyberKnife

CyberKnife robotic radiosurgery is a relatively new development for pancreatic cancer. Radiosurgery is the use of very accurately targeted highly focused radiation in a few (1 – 5) very large doses with the aim of obliterating a tumour completely. It can only be given to small areas but is a promising therapy for locally advanced inoperable disease or for patients who would otherwise have surgery but are not fit enough.

Chemotherapy

Patients with metastatic pancreatic cancer (stage IV) have a poor prognosis, with survival averaging only three to six months. Chemotherapy may be offered as a means of slowing the spread of the disease or to relieve disease-related symptoms.

Many different chemotherapeutic drugs and drug combinations have been studied. To date, none has consistently been proven to be more effective than single agent Gemcitabine.

How do you treat signs and symptoms?

Treatment for pancreatic cancer may include a number of other therapies to improve disease-related symptoms.

The symptoms that are most often treated include jaundice, bowel obstruction, pain, and weight loss.

Jaundice is caused by an obstruction of the flow of bile through the common bile duct into the intestine. The most common treatment is the placement of a stent, which is a small tubular device that is inserted into a duct to keep it open. The stent can usually be placed through an endoscope during an ERCP procedure. Initially, a plastic stent is placed, particularly if surgical removal of the cancer is possible. However, plastic stents often get clogged by debris and may become infected and require replacement. Once a decision is made that surgery is not possible, the plastic stent is replaced with a metal one.

If stenting is not possible due to technical reasons, bypass surgery can be done to create a detour around the blockage and restore the drainage of bile. However, this is rarely necessary.

About 15 to 20 percent of patients with pancreatic cancer will develop an obstruction in the duodenum caused by growth of tumour into this part of the small intestine, or from compression from a growing tumour which is outside of the duodenum in the head of the pancreas. A preventive bypass surgery may be performed to create a detour between the stomach and a lower part of the intestine.

Many patients with pancreatic cancer have abdominal pain because the pancreas lies in front of the celiac plexus, the nerve center for many of the abdominal organs. Cancers affecting the pancreas can grow locally and invade this structure, causing severe pain that can be difficult to control. In some patients, medication alone is enough to control the discomfort. Radiation therapy may also help alleviate pain in some cases by shrinking the tumor.

An additional treatment that is being used with increasing frequency is celiac plexus neurolysis (CPN). In this procedure, nerves that transmit pain signals from the area of the tumour are injected with alcohol so that they are unable to transmit signals normally. This procedure can be performed in one of three ways: in the operating theatre at the time of the initial surgical exploration, by a radiologist using a needle that is inserted into the area of the celiac plexus from outside of the body under CT guidance, or through an endoscope by a specially trained gastroenterologist, using endoscopic ultrasound.

Weight loss is common in patients with pancreatic cancer. There can be many causes. One cause is related to a decrease in the absorption of food due to a lack of the pancreatic enzymes that are found in pancreatic juice. Some patients benefit from taking pancreatic enzyme replacement. Other causes of weight loss, such as vomiting or depression, can also be addressed and treated.

What is Liver?

The liver is one of the largest organs in the body. It is located below the right lung and under the ribcage.

The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm (a sheet of muscle separating the chest and the abdomen), and on top of the stomach, right kidney, and intestines. The gall bladder is attached to the lower portion of the right side of the liver.Shaped like a cone, the liver is a dark reddish-brown organ that weighs about 1.2 kg.

There are two distinct sources that supply blood to the liver:

Oxygenated blood flows in from the hepatic artery

Nutrient-rich blood flows in from the hepatic portal vein

The liver holds about 500 ml (13 percent) of the body’s blood supply at any given moment.The liver consists of two main lobes – the right and the left, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).

What does the liver do?

The liver regulates most chemical levels in the blood and excretes a product called “bile,” which helps carry away waste products from the liver. All the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body

The liver is the most complex and metabolically active organ in the body. It performs more than 500 vital functions. Some of the important ones are

It provides immunity against infection. Hence if the liver is damaged, infections are more likely.

It is the factory for manufacturing most of the important proteins in the body, and also cholesterol and special fat forms called lipoproteins in which all body fats are carried.

It clears the blood of most chemicals, drugs and alcohol.

It excretes bile into the intestine. Bile is vital for digestion of fats, and also serves to throw out body wastes.

It regulates clotting of blood by manufacturing vital proteins

It converts and stores extra sugar (glucose) in the form of starch (glycogen) which can be used in times of starvation.

What makes the liver unique?

Reserve

All liver functions remain normal even if 70% of it is removed (provided the remaining 30% is healthy). Hence, in persons with cancer of the liver, large portions of cancerous liver can be removed without causing harm or compromise to liver function. Similarly, more than half the liver can be removed from the donor for transplantation purposes, without causing any derangement of liver function or any other serious harm to the donor.

Regeneration

The liver is the only organ in the body which can regenerate itself after large portions of it are removed. Small remnants of liver grow back to normal size within a few weeks. This is another reason why it is safe to remove large portions of liver from living donors and persons with liver tumours.

This is also why half livers transplanted into liver failure patients are very successful since they soon grow to normal size.

What is liver cancer?

Primary liver cancer (or hepatocellular cancer) is cancer that forms in the tissues of the liver.

Secondary liver cancer ( or metastatic liver cancer) is cancer that spreads to the liver from another part of the body. Cancers that commonly spread to the liver include colon, lungand breast cancers

Cancer can start within the liver (primary liver cancer or spread to the liver) from other sites, such as the colon. Cancer that starts in the liver is the fifth most common cancer in the world

Liver cancer is a bad cancer. It has frequently spread beyond the liver by the time it is discovered, and only 5% of patients with liver cancer that has begun to cause symptoms survive even five years without treatment. The only hope for patients who are at risk for liver cancer is regular surveillance so that the cancers can be found early.

What are liver cancer causes and risk factors?

1. Hepatitis B infection

Hepatitis B can be caught from contaminated blood products or used needles or sexual contact but is frequent among Asian children from contamination at birth or even biting among children at play.

The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association.

The frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer.

How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous.

2. Hepatitis C infection

Hepatitis C virus (HCV) infection is more difficult to get than hepatitis B

It usually requires direct contact with infected blood, either from contaminated blood products or needles.

HCV is also associated with the development of liver cancer.

In hepatitis C virus patients, the risk factors for developing liver cancer include the presence of cirrhosis, older age, male gender, elevated baseline alpha-fetoprotein level (a blood tumor marker), alcohol use, and co-infection with hepatitis B virus..

The way in which hepatitis C virus causes liver cancer is not well understood. Unlike hepatitis B virus, the genetic material of hepatitis C virus is not inserted directly into the genetic material of the liver cells.

It has been suggested that the core (central) protein of hepatitis C virus is the culprit in the development of liver cancer.

3. Alcohol

Cirrhosis caused by chronic alcohol consumption is the most common association of liver cancer in the developed world

Many of these people are also infected with chronic hepatitis C virus.

The usual setting is an individual with alcoholic cirrhosis who has stopped drinking for 10 years and then develops liver cancer. It is somewhat unusual for an actively drinking alcoholic to develop liver cancer. What happens is that when the drinking is stopped, the liver cells try to heal by regenerating (reproducing). It is during this active regeneration that a cancer-producing genetic change (mutation) can occur, which explains the occurrence of liver cancer after the drinking has been stopped.

More importantly, if an alcoholic does not stop drinking, he or she is unlikely to live long enough to develop the cancer. Alcoholics who are actively drinking are more likely to die from non-cancer related complications of alcoholic liver disease (for example, liver failure).

Indeed, patients with alcoholic cirrhosis who die of liver cancer are about 10 years older than patients who die of non-cancer causes.

Finally, alcohol adds to the risk of developing liver cancer in patients with chronic hepatitis C virus or hepatitis B virus infections.

4. Aflatoxin B1

Aflatoxin B1 is the most potent liver cancer-forming chemical known. It is a product of a mold called Aspergillus flavus, which is found in food that has been stored in a hot and humid environment.

This mold is found in such foods as peanuts, rice, soybeans, corn, and wheat.

Aflatoxin B1 has been implicated in the development of liver cancer in Southern China and sub-Saharan Africa.

It is thought to cause cancer by producing changes (mutations) in the p53 gene. These mutations work by interfering with the gene’s important tumor suppressing (inhibiting) functions.

5. Drugs, medications, and chemicals

There are no medications that cause liver cancer, but female hormones (estrogens) and protein-building (anabolic) steroids are associated with the development of hepatic adenomas. These are benign liver tumors that may have the potential to become malignant (cancerous). Thus, in some individuals, hepatic adenoma can evolve into cancer.

Certain chemicals are associated with other types of cancers found in the liver. For example, thorotrast, a previously used contrast agent for diagnostic imaging studies, caused a cancer of the blood vessels in the liver called hepatic angiosarcoma. Also, vinyl chloride, a compound used in the plastics industry, can cause hepatic angiosarcomas that appear many years after the exposure.

6. Hemochromatosis

Liver cancer will develop in up to 30% of patients with hereditary hemochromatosis (a disorder in which there is too much iron stored in the body, including in the liver). Patients at the greatest risk are those who develop cirrhosis with their hemochromatosis. Unfortunately, once cirrhosis is established, effective removal of excess iron (the treatment for hemochromatosis) will not reduce the risk of developing liver cancer.

7. Diabetes and obesity

It is hard to separate the effects of diabetes from that of obesity on the liver as both conditions can cause chronic damage and accumulation of fat within the liver.. This is a disease called NASH (non-alcoholic steatohepatitis) Fatty liver disease like this causes damage to the individual liver cells and may lead to cirrhosis in some people, thereby increasing the risk of liver cancer.

Not only is the chance of developing the cancer enhanced, but patients with diabetes who undergo surgical removal of liver cancer have a higher chance of the cancer returning than do those without diabetes.

8. Cirrhosis

Individuals with most types of cirrhosis of the liver are at an increased risk of developing liver cancer.

In addition to the conditions described above (hepatitis B, hepatitis C, alcohol, and hemochromatosis), alpha 1 anti-trypsin deficiency, a hereditary condition that can cause emphysema and cirrhosis, may lead to liver cancer.

Liver cancer is also strongly associated with hereditary tyrosinemia, a childhood biochemical abnormality that results in early cirrhosis

What are symptoms and signs of liver cancer?

Primary cancer arises within the liver and in its early stages exists only within the liver. At an early stage, primary liver cancer may cause no symptoms at all. More advanced disease may cause loss of appetite, weight loss, fever, fatigue and weakness.

Secondary liver cancer is the term for cancer that originates in another organ, such as the colon, stomach, pancreas and breast, and then spreads to the liver. As the cancer grows, pain may develop in the upper abdomen on the right side and may extend into the back and shoulder. With advanced disease, the signs of liver failure appear, which include abdominal swelling and a feeling of fullness or bloating and jaundice, a condition in which the skin and the whites of the eyes become yellow and the urine becomes dark.

How do you diagnose liver Cancer ?

In making a diagnosis of liver cancer, your doctor will evaluate your medical history and perform a careful physical examination. Certain tests also will be recommended.

For people at increased risk of developing primary liver cancer, such as those with chronic viral hepatitis or cirrhosis, the current recommendation is to have an alpha-fetoprotein blood test and an ultrasoundexamination of the liver, at least annually. While not perfect, these tests increase the chances of detecting liver cancer at an early stage.

Certain blood tests like liver function test are used to see how well the liver is functioning.

X-rays of the chest and abdomen, angiograms or X-rays of blood vessels; CT scans, or X-rays put together by computer; and magnetic resonance images (MRIs), created by using a magnetic field, may be part of the diagnostic process.

If there is uncertainty about the diagnosis, the presence of liver cancer may be confirmed with a biopsy. Tissue from the liver is removed through a needle or during an operation and checked under a microscope for the presence of cancer cells.

Your doctor also may look at the liver with an instrument called a laparoscope, which is a small tube-shaped instrument with a light on one end. For this procedure, a small cut is made in the abdomen so that the laparoscope can be inserted. Your doctor may take a small piece of tissue during the laparoscopy. A pathologist then examines the tissue under the microscope to see if cancer cells are present.

Once primary liver cancer is found, more tests will be performed to determine if cancer cells have spread to other parts of the body.

Staging of liver cancer

The following stages are used for adult primary liver cancer:

Localized resectable — Cancer is found in one place in the liver and can be completely removed by surgery.

Localized unresectable — Cancer is found only in one part of the liver, but the cancer cannot be totally removed.

Advanced — Cancer has spread through much of the liver or to other parts of the body.

Recurrent — Cancer has come back or recurred after it was treated.

What are the treatment options for liver cancer?

The best possible treatment a liver cancer is surgery wherein the affected portion of the liver is removed (“hepatectomy”).

If surgery is performed at a time when the cancer is confined to a removable portion of the liver and has not spread elsewhere, there is a high chance of cure.

Two unique features of the liver help in good recovery of patients. One is the tremendous reserve due to which liver function remains normal even if upto 70% liver is removed as long as the remaining liver is not diseased. The second is the power of regeneration due to which the liver recovers its original weight within few weeks after removal of up to 60-70% of liver.

In some suitable cases, especially those where the liver has cirrhosis along with cancer, liver transplantation is also possible. This procedure can treat both liver cirrhosis and cancer at the same time.

Treatment without operation

If an operation is not possible or safe, there are now several other treatment options available.

Alcohol injection and radiofrequency thermoablation (RFA, burning the tumour with a special probe without operation) are two excellent options. Both these procedures destroy the tumour without any significant harm to the rest of the liver or the body and can be done on an outpatient basis without the need for admission to hospital. However, their major limitation is that they are only effective for cancers less than about 2 inches in size and fewer than three in number.

Injection of chemotherapy drugs through the liver arteries (transarterial chemotherapy or TAC) can be done if the cancer is widespread within the liver. This way the drugs are delivered directly to the tumour greatly enhancing their effectiveness and at the same time, markedly reducing their side effects on the rest of the body.

Another method by which liver surgeons can deal with large or multiple tumours that are confined to one side of the liver is by blocking the blood supply of the cancerous area of the liver with chemotherapy impreganted material (transarterial chemo-embolization or TACE) resulting in death of tumour cells. All above treatments can and should only be carried out in specialized liver centres by experienced liver surgeons, physicians and radiologists.

Radiofrequency Ablation (RFA) as Liver Cancer Treatment

Radiofrequency ablation, is a technique of heating up liver cancers with probes inserted into the cancers. The probe is hooked to a machine which drives current in a high frequency alternating—back and forth–path which results in heating the liver tissue to the level of 90 to 100 degrees Centigrade (100 degrees C=212 degrees Fahrenheit).

This temperature cooks the tissues around it. A straight needle like probe will cook the tissues around it in a limited elliptical fashion which will not kill or “ablate” all of the cancer it is put in, except for the very smallest cancers.

Chemoembolization(TACE)

Chemoembolization is also known as TACE, standing for transarterial chemoembolization.

In this technique an interventional radiologist injects a chemotherapeutic agent directly into the arteries supplying a tumor within the liver. Frequently lipiodol is also injected since lipiodol, which is actually poppyseed oil, will hold the chemical there within the injected artery for a longer time

Chemoembolization may be superior to bland embolization, which is the injection of agents to cause the artery to clot off, without adding chemotherapy drugs along with the clotting agents

This treatment method is used more frequently in the patient with hepatocellular carcinoma than in the patient with metastasis from a cancer of the colon or rectum.

A post-embolization syndrome does occur in many patients after TACE that makes them sick for several days post-procedure.

TACE is a second line therapy that should only be considered after ablation or resection have been ruled out.

Chemotherapy

The most commonly used systemic chemotherapeutic agents are doxorubicin (Adriamycin) and 5-fluorouracil (5 FU).

How can you prevent liver cancers?

Prevention of liver cancer is possible at two levels.

The first level of prevention is to avoid alcohol abuse and to prevent the occurrence of Hepatitis B or Hepatitis C. These are acquired from infected individuals via blood or rarely other secretions, by sharing of infected needles among drug addicts, or by the sexual route. Their transmission can be avoided by use of disposable needles in hospitals, by strict and universal screening of all blood donors in blood banks and refusing donations from infected persons. The spread of Hepatitis B can be curbed by universal vaccination of all newborns and the rest of the non-infected population.

The second level of prevention is in patients who have liver cirrhosis. A significant proportion of them will develop cancer. This can be avoided if they undergo a timely liver transplant and the diseased liver can be removed. All those with cirrhosis should see a liver specialist to find out if a liver transplant is suitable for them.

What is stomach cancer?

Stomach cancer (also called gastric cancer) starts in the stomach. After food has been chewed and swallowed, it passes down a tube called the esophagus and empties into the stomach. The stomach is a sack-like organ that holds food and mixes it with gastric juice to begin the process of digestion.

Stomach cancer, also called gastric cancer, begins when cells in the stomach become abnormal and grow uncontrollably. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

Cancer can start in any part of the stomach. Symptoms, treatment options, and the outlook for survival can all vary depending on where the cancer begins.

The stomach itself is made up offive layers. Starting from the inside and working out:

The innermost layer is called the mucosa – This is where the stomach acid and digestive juices are made
Next is a supporting layer called the submucosa
This is surrounded by the muscularis, a layer of muscle that moves and mixes the stomach contents.
The next 2 layers, the subserosa and the serosa (the outermost layer) act as wrapping for the stomach.

Most of the time stomach cancer starts in the mucosa.

Stomach cancer probably grows slowly over many years. Before a true cancer develops, there are usually changes that take place in the lining of the stomach. These early changes rarely produce symptoms and therefore often are not noticed.

Stomach cancer can spread in several different ways:

It can grow through the wall of the stomach and eventually grow into nearby organs.

It can also spread to the lymph nodesand then through the lymph system. If cancer spreads this way, the outlook for a cure gets worse.

When stomach cancer is more advanced, it can travel through the bloodstream and form deposits of cancer cells in organs such as the liver, lungs, and bones.

Most cancers of the stomach are of a type called adenocarcinomas. This cancer develops from cells that form the lining of the innermost layer, the mucosa. The term “stomach cancer” almost always refers to this type of cancer. Lymphomas, gastric stromal tumors, and carcinoid tumors are other, much less common, tumors that are found in the stomach.

What causes stomach cancer?

The major risk factors for stomach cancer are listed below:

Bacterial infection: Many doctors think that infection with bacteria called Helicobacter pylori may be a major cause of stomach cancer. Long-term infection with this germ can lead to inflammation and damage to the inner layer of the stomach, a possible pre-cancerous change. This bacterium is also linked to some types of lymphoma of the stomach. But most people who carry this germ in their stomachs never develop cancer.

Diet: An increased risk of stomach cancer is linked to diets high in smoked foods, salted fish and meats, and pickled vegetables. On the other hand, eating whole grain products and fresh fruits and vegetables that contain vitamins A and C appears to lower the risk of stomach cancer.

Tobacco and alcohol abuse: Smoking just about doubles the risk of stomach cancer for smokers. While some studies have linked alcohol use to stomach cancer, this is not certain.

Obesity: Being very overweight (obese) is a major cause of many cancers, including cancer of the stomach.

Earlier stomach surgery: Stomach cancer is more likely to occur in people who have had part of their stomach removed to treat other problems such as ulcers.

Pernicious anemia: In this disease, the stomach doesn’t make enough of a protein that allows the body to absorb vitamin B12 from foods. This can lead to anemia (a shortage of red blood cells). Patients with this disease also have a slightly increased risk of stomach cancer.

Menetrier disease: This rare disease involves changes in the stomach lining that in turn are linked to a risk of stomach cancer.

Gender: Stomach cancer is more common in menthan it is in women.

Ethnicity: The rate of stomach cancer is higher in Hispanics and African Americans than in non-Hispanic whites. The highest rates are seen in Asian/Pacific Islanders.

Age: There is a sharp increase in stomach cancer after the age of 50.

Type A blood: For unknown reasons, people with type A blood have a higher risk of getting stomach cancer.

Family history: People with several close relatives who have had stomach cancer are more likely to develop this disease. Also, some families have a gene change (mutation) that puts them at greater risk for getting colorectal cancer and a slightly higher risk of stomach cancer.

Stomach polyps: Polyps are small mushroom-like growths of the lining of the stomach. Most types of polyps do not increase the risk of stomach cancer. But one type (adenomatous polyps) sometimes develops into stomach cancer.

Geography: Stomach cancer is most common in Japan, China, Southern and Eastern Europe, and South and Central America. This disease is less common in Northern and Western Africa, Melanesia, South Central Asia, and North America.

Epstein-Barr virus: This virus causes “mono” (infectious mononucleosis). It has been found in the stomach cancers of some people.

While there are many risk factors for stomach cancer, we do not know exactly how these factors cause cells of the stomach to become cancerous. Scientists are trying to learn how and why certain changes take place in the lining of the stomach and what part H. pylori plays in stomach cancer.

What are the symptoms of this cancer?

People with stomach cancer may experience the following symptoms or signs. Sometimes, people with stomach cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Stomach cancer is usually not found at an early stage because it often does not cause specific symptoms. When symptoms do occur, they may be vague and can include:

Indigestion or heartburn

Pain or discomfort in the abdomen

Nausea and vomiting, particularly vomiting up of solid food shortly after eating

Diarrhea or constipation

Bloating of the stomach after meals

Loss of appetite

Sensation of food getting stuck in the throat with eating

Symptoms of advanced stomach cancer may include:

Weakness and fatigue

Vomiting blood or having blood in the stool

Unexplained weight loss

It is important to remember that these symptoms can also be caused by many other illnesses, such as a stomach virus or an ulcer. People with any of the symptoms listed above should talk with their doctor.

How do you diagnose stomach cancer?

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

The type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose stomach cancer:

Biopsy A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Endoscopy This test allows the doctor to see the inside of the body. The person may be sedated, and the doctor inserts a thin, lighted, flexible tube called a gastroscope or endoscope through the mouth, down the esophagus, and into the stomach and small bowel. The doctor can remove a sample of tissue during an endoscopy and check it for evidence of cancer.

Endoscopic ultrasound This test is similar to an endoscopy, but the gastroscope has a small ultrasound probe on the end that produces a detailed image of the stomach wall. An ultrasound uses sound waves to create a picture of the internal organs. The ultrasound image helps doctors determine how far the cancer has spread into the stomach and nearby lymph nodes, tissue, and organs, such as the liver.

X-ray An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.

Barium swallow In a barium swallow, a person swallows a liquid containing barium, and a series of x-rays are taken. Barium coats the lining of the esophagus, stomach, and intestines, so tumors or other abnormalities are easier to see on the x-ray.

Computed tomography (CT or CAT) scan A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI) An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Positron emission tomography (PET) scan.

A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Laparoscopy A laparoscopy is a minimally invasive surgery in which the surgeon inserts a scope into the abdominal cavity to evaluate spread of the stomach cancer to the lining of the abdominal cavity or liver. This pattern of spread of the cancer is not detected by CT or PET scan.

Staging

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis (chance of recovery

One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatment.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How far has the primary tumor extended into the stomach? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Recurrent cancer. Recurrent cancer is cancer that comes back after treatment. It may be a localized recurrence (comes back in the place where it started), or it may be a distant metastasis (comes back in another part of the body).

How do you treat stomach cancer ?

No matter what stage of stomach cancer you have, there is treatment. The choice of treatment you receive depends on many factors. The place and stage of the tumor are very important, of course. But other factors include your age, your overall health, and your personal wishes.

The main treatments for stomach cancer are:

Surgery

Chemotherapy

Radiation therapy

Often the best approach involves using 2 or more of these treatment methods. Your recovery is one goal of your cancer care team. If a cure is not possible, treatment is aimed at relieving symptoms such as trouble eating, pain, or bleeding. Before you start treatment it is important that you understand the goal of your treatment– whether it is to cure or to relieve symptoms.

Surgery

Depending on the type and stage of your cancer, surgery might be used to remove the cancer and that part of the stomach where it is attached. The surgeon will try to leave behind as much normal stomach as possible. At this time, surgery is the only way to cure stomach cancer. If you have stage 0, I, II, or IIII cancer, and if you are healthy enough, an attempt should be made to treat the cancer by completely removing it. Even if the cancer is too widespread to be completely removed by surgery, an operation could help prevent bleeding from the tumor or keep the stomach from becoming blocked. This type of surgery is known as palliative, meaning that it relieves or prevents symptoms but is not expected to cure the cancer.

There are three main types of surgery for stomach cancer:

Endoscopic mucosal resection: Resection refers to the removal of a tumor or part of an organ by cutting it out. With this method, the cancer is removed through the endoscope. This can be done only for very early cancers where the chance of spread to the lymph nodes is very low.

Subtotal(partial) gastrectomy: This approach can be used if the cancer is in the lower part of the stomach close to the intestines. Only part of the stomach is removed, sometimes along with the first part of the small intestine. Eating is much easier with this approach rather than when the whole stomach is removed.

Total gastrectomy: This method is used if the cancer is in the middle or upper part of the stomach. The surgeon removes the entire stomach. Because the stomach holds and digests food, when it is removed a person will fill up after only a few mouthfuls. To solve this problem, the surgeon will try to make a new “stomach” out of intestinal tissue. No matter how effective this is, people who have had a total gastrectomy can only eat a small amount of food at a time. Because of this, they must eat more often.

If surgery is done to cure the cancer, the lymph nodes and some of the fatty tissue (omentum) around the stomach are removed as well. If the cancer has spread beyond the stomach to the spleen, it will be removed too.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Patients with stomach cancer usually receive external-beam radiation therapy, which is radiation given from a machine outside the body. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells.

Side effects from radiation therapy include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body.

Chemotherapy can be given by mouth (orally) or injection. The goal of chemotherapy can be to destroy cancer remaining after surgery, slow the tumor’s growth, or to reduce cancer-related symptoms. It also may be combined with radiation therapy.

In addition, patients whose stomach tumors have too much of the protein HER2 (called HER2-positive cancer) may benefit from the addition of trastuzumab (Herceptin) to chemotherapy in advanced stomach cancer. For more information about targeted therapies, such as trastuzumab,

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Biological therapy

Biological therapy (also called immunotherapy) is a form of stomach cancer treatment that helps the body’s immune system attack and destroy cancer cells;
it may also help the body recover from some of the side effects of treatment. In clinical trials, doctors are studying biological therapy in combination with other treatments to try to prevent a recurrence of stomach cancer.
In another use of biological therapy, patients who have low blood cell counts during or after chemotherapy may receive colony-stimulating factors to help restore the blood cell levels.
Patients may need to stay in the hospital while receiving some types of biological therapy.
Advanced stomach cancer

Advanced stomach cancer has spread to other areas of the body and is generally treated the same way as earlier stages of the disease, with surgery, chemotherapy, or radiation therapy.

Doctors may also recommend ways to relieve symptoms, called supportive care or palliative care. For instance, surgery can prevent intestinal or stomach blockages. Chemotherapy or radiation therapy can also help relieve symptoms.

What are the side effects of treatment?

It is hard to limit the side effects of stomach cancer therapy so that only cancer cells are removed or destroyed. Because healthy cells and tissues also may be damaged, treatment for stomach cancer can cause unpleasant side effects.

The side effects of stomach cancer treatment are different for each person, and they may even be different from one treatment to the next.

Side effects of surgery

Gastrectomy is major surgery. For a period of time after the surgery, the person’s activities are limited to allow healing to take place.

For the first few days after surgery, the patient is fed intravenously (through a vein). Within several days, most patients are ready for liquids, followed by soft, then solid, foods.

Those who have had their entire stomach removed cannot absorb vitamin B12, which is necessary for healthy blood and nerves, so they need regular injections of this vitamin.

Patients may have temporary or permanent difficulty digesting certain foods, and they may need to change their diet.

Some gastrectomy patients will need to follow a special diet for a few weeks or months, while others will need to do so permanently.

Some gastrectomy patients have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly. This group of symptoms is called the dumping syndrome. Foods containing high amounts of sugar often make the symptoms worse. The dumping syndrome can be treated by changing the stomach cancer patient’s diet. Doctors often advise patients to eat several small meals throughout the day, to avoid foods that contain sugar, and to eat foods high in protein.

To reduce the amount of fluid that enters the small intestine, patients are usually encouraged not to drink at mealtimes. Medicine also can help control the dumping syndrome. The symptoms usually disappear in 3 to 12 months, but they may be permanent.

Following gastrectomy, bile in the small intestine may back up into the remaining part of the stomach or into the esophagus, causing the symptoms of an upset stomach. The patient’s doctor may prescribe medicine or suggest over-the-counter products to control such symptoms.

Side effects of chemotherapy

The side effects of chemotherapy depend mainly on the drugs the patient receives.

As with any other type of stomach cancer treatment, side effects also vary from person to person. In general, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body.

When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy.

Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result of chemotherapy, stomach cancer patients may have side effects such as loss of appetite, nausea, vomiting, hair loss, or mouth sores. These effects usually go away gradually during the recovery period between treatments or after the stomach cancer treatments stop.

Side effects of radiation therapy

Patients who receive radiation to the abdomen may have nausea, vomiting, and diarrhea.

The skin in the treated area may become red, dry, tender, and itchy. Patients should avoid wearing clothes that rub; loose-fitting cotton clothes are usually best. It is important for patients to take good care of their skin during treatment, but they should not use lotions or creams without the doctor’s advice.

Stomach cancer patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Side effects of biological therapy

The side effects of biological therapy vary with the type of treatment. Some cause flu-like symptoms, such as chills, fever, weakness, nausea, vomiting, and diarrhoea

Patients sometimes get a rash, and they may bruise or bleed easily. These problems may be severe, and patients may need to stay in the hospital during treatment.

Recovery & Follow Up

Rehabilitation and followup care is an important part of the overall stomach cancer treatment process. The goal of stomach cancer rehabilitation is to improve a person’s quality of life. The medical team, which may include doctors, nurses, a physical therapist, an occupational therapist, or a social worker, develops a stomach cancer rehabilitation plan to meet each patient’s physical and emotional needs, helping the patient return to normal activities as soon as possible.

Cancer patients and their families may need to work with an occupational therapist to overcome any difficulty in eating, dressing, bathing, using the toilet, or other activities. Physical therapy may be needed to regain strength in muscles and to prevent stiffness and swelling. Physical therapy may also be necessary if an arm or leg is weak or paralyzed, or if a patient has trouble with balance.

It is important for people who have had stomach cancer to continue to have examinations regularly after their stomach cancer treatment is over. Followup care ensures that any changes in health are identified, and if there is a recurrence of stomach cancer, it can be treated as soon as possible. Checkups may include a careful physical exam, imaging procedures, endoscopy, or lab tests.

Between scheduled appointments, people who have had stomach cancer should report any health problems to their doctor as soon as they appear

Living with stomach cancer

Living with a serious disease like stomach cancer is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful stomach cancer information and support services.

Cancer patients may worry about holding their job, caring for their family, or keeping up with their daily activities. Concerns about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses, and other members of the health care team can answer questions about stomach cancer treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy also can be helpful for patients who want to talk about their feelings or discuss their concerns about the future or about personal relationships.

Friends and relatives can be very supportive. Also, it helps many stomach cancer patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups for stomach cancer, where they can share what they have learned about coping with cancer and the effects of stomach cancer treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another — even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

Breast Cancer

The breasts, also known as mammary glands, are a pair of glandular organs that produce milk in response to the hormone changes of childbirth. They are mainly made up of fatty tissue that starts high on the front of the chest and extends down and around into the armpit. They are supported by ligaments and large muscles.

Each breast has 15-20 lobes with a number of lobules and ducts supportive tissue (see diagram). Each lobule has about 30 major ducts that open onto the nipple. The darker area of skin around the nipple is called the areola. At the edge of the areola there are large glands that produce fluid to lubricate the nipple.

In each armpit there are about 20-30 lymph nodes (glands) that drain fluid from the breast. These form part of the lymphatic system that helps the body to fight infection.

Breast cancer is an abnormal growth of cells which are not controlled . These cells cause invasion and destruction of the breast tissue. That changed cell gains the ability to keep dividing to form a cancerous growth.

Breast cancer is the most common type of cancer affecting women in India. However, extensive research and technological advances in diagnosis and treatment makes breast cancer “the best among the worst”! Not to glorify it, but if detected early, breast cancer can be treated well with minimal morbidity to the patient.

Here are some FAQs answered!

Why me?

Honestly, no amount of training teaches doctors how to answer this question!

Scientifically speaking, breast cancer is a multifactorial disease. It results as a combination of excess circulating estrogen, advancing age and bad genes. All women have a baseline level of estrogen. But the risk of cancer is determined by the number of years the breasts are exposed to unopposed estrogen action. Estrogen and progesterone are two hormones required for the growth of breast. While estrogen promotes the proliferation of cells in the breast, progesterone antagonises it. Progesterone is the hormone of pregnancy. Hence, women who have never been pregnant or who attain early menarche, late menopause are exposed to longer periods of sustained estrogen action and have increased risk of breast cancer.

But, Why me? No one knows why.

What is BRCA?

BRCA 1 and BRCA 2 are genes present in our chromosome. Mutation of these genes may be inherited. Mutated BRCA genes increase the risk of breast cancer to up to 85%. They also lead to other hereditary cancers like ovarian cancer, pancreatic cancer and colon cancer. Breast cancer caused by BRCA mutation has some specific traits. They are very aggressive tumors which might affect both the breasts at multiple sites and they strike at a younger age. If there is a family history of breast and ovarian cancers affecting younger women, consult a doctor to get tested for BRCA mutation. A blood sample is drawn and the DNA is screened for the mutation. Intensive pre test and post test counselling will be required to prepare the patients to deal with the results of the test.

How do I screen myself for breast cancer?

The American cancer society recommends any woman above the age of 40 years to undergo a screening mammography as part of the routine annual health check up. A mammogram is a form of X-RAY of the breasts. It helps to detect any breast lump which is very small to be detected by clinical examination. A mammogram is not done in younger women because young women have dense breast tissue which might be falsely detected as a breast lump. Women from high risk families – families tested positive for BRCA mutation may have to undergo a screening MR mammography regularly to detect breast lumps.

Will routine mammography increase the risk of breast cancer?

No. It is true that the mammography machine uses X-rays which are 4 times stronger than the routine chest x-rays. However, there are no studies to prove that yearly mammography will increase the risk of cancer.

I felt a lump in my breast. What do I do now?

Do not panic. Not all breast lumps are cancerous. Consult a surgeon and get yourself examined. Based on the clinical examination, the doctor may advise you to get an ultrasound of the breast. There are certain definitive features of a cancerous lump which can be differentiated from a benign lump. If there are features suspicious of cancer, a small sample of the lump will be obtained using a needle (either FNAC or Trucut biopsy) and will be further tested to confirm cancer.

What is carcinoma-in situ?

Cancer is a mass of cells which divide in an unregulated manner. These cells rest on a basement membrane. As long as the rapidly dividing cells are limited by a basement membrane, the cancer remains localised. This is called carcinoma-in situ. It is the earliest stage of cancer. Once the cells invade the basement membrane, they can spread to other organs via blood vessels or lymphatics.

I have been diagnosed with early invasive breast cancer. How early is “early” ?

All cancers are staged on a scale of stage 0 to stage 4. Carcinoma in situ is stage 0 and a metastatic cancer is stage 4. Other stages vary with different cancers. With respect to breast cancers, early invasive breast cancer is one which has not spread beyond the breast and axillary lymph nodes.

How would I know if the tumor in my breast has spread?

there are several blood tests and scans to be done to detect the spread of cancer.

Chest X ray – To detect spread to the lungs

CT scan – It provides high definition images of probable cancer spread to the liver and lungs. CT scan images can also guide the surgeon to take biopsy

MRI – It detects spread to the brain and spinal cord

PET scan – the patient is given a radioactive sugar solution. this sugar binds to cancer cells which can be detected using special camera. A PET scan is done to asses spread of the cancer when the surgeon is not sure of the exact location of spread from clinical examination.

What is Breast conservation surgery?

Any patient with early invasive breast cancer (stage 0, I and II) can be treated with breast conservation surgery. The goal is to preserve the breast tissue and shape as much as possible. Only the lump and some normal tissue surrounding it is removed. However, Breast conservation surgery is always followed by radiation therapy.

What is sentinel lymph node?

Breast cancer spreads through lymphatic channels. A sentinel lymph node is the first lymph node along the lymphatic channels to receive lymph from an organ. The lymph from the breast first drains into the lymph nodes present in the armpit. Hence, if the right breast has a cancerous lump, the cancer cells would have to first reach the lymph nodes in the right armpit and only then it would spread to the rest of the body.

What is sentinel lymph node biopsy?

A biopsy of the sentinel lymph node is done when no node is felt in the armpit during clinical examination. A dye is injected through the skin over the breast and a small cut is made in the armpit to identify the first lymph node which is stained by the dye. This node is sent to the lab to detect cancer cells while the patient is still in the operation theater under anesthesia. It usually takes about 30 minutes for a report. If there are no cancer cells found in this biopsy, it means the cancer has not spread to the lymph nodes and a mere removal of the breast lump would suffice. If the biopsy shows cancer cells, then the surgeon would remove lymph nodes from the armpit too.

What is locally advanced breast cancer?

Locally advanced breast cancer is one which is larger than early breast cancer but still confined to the breast and axillary lymph nodes. Such patients may require chemotherapy first to reduce the size of the lump. This would be followed by surgery and radiation therapy.

What is ER/PR status?

ER and PR stand for Estrogen Receptor and Progesterone Receptor respectively. If the tumor is positive for these receptors such patients are likely to respond to hormone therapy. Drugs like Tamoxifen is very useful in such patients and it reduces the risk of recurrence of cancer in the other breast. tumors negative for these receptors will not respond to hormone therapy and such patients will have to be given chemotherapy.

What is Her2-nu?

Her2nu is Herceptin receptor. Tumors which have this receptor tend to be more aggressive and rapidly growing. However, drugs targeted against the receptor are available, like Trastuzumab.

What are the treatment options available for metastatic breast cancer?

Breast cancer which has spread to other parts of the body is managed by appropriately dosed hormone therapy, chemotherapy and radiation therapy. The role of surgery in advanced metastatic cancer is very minimal.

What is breast reconstruction surgery?

Several oncoplastic surgeries are done to reconstruct the breast for women who have undergone mastectomy. The patient’s own abdominal muscles or muscles of the back are used to reconstruct the breast. A silicone prosthetic breast may also be used.

Does obesity increase the risk of breast cancer?

Yes. The main source of estrogen in postmenopausal women is estrogen from fatty tissue. Obese women are exposed to estrogen for longer time period and this increases the risk of breast cancer.

Does use of birth control pills increase the risk of breast cancer?

30-40 % risk is seen in girls under the age of 18 who regularly use this method of contraception. HRT (Hormone Replacement Therapy) used by post -menopausal women increases the risk (63%) of development of breast cancer. However, HRT may be required to control other symptoms of menopause. So women using HRT must undergo regular Mammography and screen themselves for breast cancer.

Should I worry if my 16 year old daughter has breast lumps?

No. Adolescent girls may have multiple breast lumps. These are called fibroadenomas. They occur due to hormonal imbalance. However is it advisable to get it examined and scanned to confirm the diagnosis.

Can breast surgeries be done as short stay surgery?

Yes, definitely. The patient can get admitted in the morning of the surgery. Surgery for breast cancer takes about 2 hours to complete. If required a drain tube will be placed under the skin. The patient can be discharged from the hospital 24 hours after the surgery.

What is the incidence of breast cancer?

Cervical cancer is the most common cancer in women in India with breast cancer competing fast with it for the top position. In a survey conducted by ICMR (Indian Council of Medical Research), it is seen that 1 out of 22 women are affected compared to 1 in every 8 women affected in US.

What are the causes for Breast Cancers?

Positive family history of breast cancer: If a woman has mother who has had breast cancer, her risk increases about 3 folds. If the woman has a sister with history of breast cancer, the risk increases by 2-3 folds.

Women who have had breast cancer in one breast

There is slightly increased risk in women who :
– have had their first childbirth late in life
– had an early menarche
– have no children
– have a late menopause

Obesity predisposes to breast cancer after menopause

Increased and long usage of OC pills

Women who taken hormones for more than 10 years

Oncogenes- related to BRCA1 and BRCA2 genes

What is HER2 – positive breast cancer?

Some women have what’s called HER2-positive breast cancer. HER2 refers to a gene that helps cells grow, divide, and repair themselves. When cells have too many copies of this gene, cells — including cancer cells — grow faster. Experts think that women with HER2-positive breast cancer have a more aggressive disease and a higher risk of recurrence than those who do not have this type

What are the symptoms of Breast cancers?

Usually breast cancers present with:

A painless mass in the breast- up to 10% of cases have pain and no mass

Breast changes- thickening, swelling and skin irritation or distortion (Dimpling of the skin in the area of the lump appearing like orange peel)

Nipple changes- discharge, erosion, inversion and tenderness( pain)

Presence of patch of dry flaky skin on the nipple and change in appearance or texture of the breasts – Usually seen in Paget’s disease.

General Symptoms- fever, loss of appetite, fatigue

What are the changes I should be aware of in Breast Cancer?

Change in size

Inverted nipple

Rash in and around the nipple

Discharge from one or both nipples

Puckering or dimpling of skin

Swelling in your armpits

Swelling in the breast

Constant pain in breast and armpit

How is breast cancer diagnosed?

The earlier the breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated successfully.

Guidelines for Early Breast Cancer Detection

The following are the guidelines for finding breast cancer early in women without symptoms:

Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, preferably every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts feel likeFor any spontaneous change, see your physician without delay!Make sure you compliment your BSE with a yearly physical exam of your breasts by a trained professional and ask about risk factors and breast screening.

Breast awareness and breast self-exam (BSE): BSE is an option for women starting in their 30s. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally feel.

When do you do breast self – examination?

Women more than 30 years of age should do BSE regularly.

BSE should be performed about one week after the beginning of each cycle.

If the periods have stopped, it should be done in the beginning of each month.

1. While standing in front of a mirror, look at the breasts. The breasts normally differ slightly in size. Look for changes in the size difference between the breasts and changes in the nipple, such as turning inward (an inverted nipple) or a discharge. Look for puckering or dimpling.

2. Watching closely in the mirror, clasp the hands behind the head and press them against the head. This position helps make subtle changes caused by cancer more noticeable. Look for changes in the shape and contour of the breasts, especially in the lower part of the breasts.

3. Place the hands firmly on the hips and bend slightly toward the mirror, pressing the shoulders and elbows forward. Again, look for changes in shape and contour.

4. Raise the left arm. Using three or four fingers of the right hand, probe the left breast thoroughly with the flat part of the fingers. Moving the fingers in small circles around the breast, begin at the nipple and gradually move outward. Press gently but firmly, feeling for any unusual lump or mass under the skin. Be sure to check the whole breast. Also, carefully probe the armpit and the area between the breast and armpit for lumps.

5. Squeeze the left nipple gently and look for a discharge. (See a doctor if a discharge appears at any time of the month, regardless of whether it happens during breast self-examination.)

Repeat steps 4 and 5 for the right breast, raising the right arm and using the left hand.

6. Lie flat on the back with a pillow or folded towel under the left shoulder and with the left arm overhead. This position flattens the breast and makes it easier to examine. Examine the breast as in steps 4 and 5. Repeat for the right breast.

Early detection guidelines:

At Age > 40 years- Annual mammogram, annual Clinical Breast examination ( CBE) and optional monthly breast self- examination ( BSE)

At Age 20-39- Every three years a CBE and optional monthly BSE

For women at average risk- who have a family history of breast cancer should talk to their doctor about when to start screening

What happens when breast cancer is suspected?

If there is any reason to think you might have breast cancer, your doctor may suggest further tests such as the ones below to confirm it.

Tests to confirm breast cancer:

Fine needle aspiration cytology (FNAC): This involves taking out a few cells from the lump with a thin needle and examining them under a microscope.

Biopsy: Sometimes, even after doing FNAC it may not be possible to find out the nature of the lump. The lump may then have to be in part or totally under following methods, under local or general anesthesia.

Stereotactic core needle biopsy: The needle used for this test is larger than the one for fine needle biopsy. It is used to remove several cylinders of tissue. The biopsy is done with local anesthesia (the area is numbed) on an outpatient basis.

Surgical biopsy: Sometimes surgery is needed to remove all or part of a lump so it can be looked at under a microscope. The entire lump as well as some normal tissue around it may be removed. Most often this is done in the hospital on an outpatient basis. Local anesthesia is used and sedation may also be given to relax you and make you less aware of the process

Mammography: This special type of x-ray of the breast is done to assess the extent of tumor in the affected breast and ascertain whether there is any abnormality in the other breast.

Sonography of the breast: Sometimes a mammography is supplemented with this test. Both the tests are useful to detect tumor and its extent but do not offer a definitive diagnosis as is done by FNAC or a biopsy.

Tests to check if breast cancer has spread:

Chest x-ray: This test may be done to see whether the cancer has spread to the lungs.

Bone scan:This test can help show whether the cancer has spread to the bones. The patient is given a very low dose of radiation. The bone attracts the radiation which will show up on the scan as a “hot spot.” These hot spots could be cancer but other problems such as arthritis can also be the cause. Therefore, x-rays of hot spots may be needed.

CT scan (computed tomography): A CT scan is a special type of x-ray. Many pictures are taken from different angles. These images are combined by a computer to produce a detailed picture of the internal organs. This test can help tell if the cancer has spread to the liver or other organs. It can also be used to guide a biopsy needle into a suspicious area.

MRI (magnetic resonance imaging):An MRI scan uses radio waves and strong magnets instead of x-rays. This test can be helpful in looking at the brain and spinal cord.

PET scan (positron emission tomography): This test uses a form of sugar that contains a radioactive atom. Cancer cells absorb high amounts of this sugar. A special camera can then spot these cells. PET is useful when the doctor thinks the cancer has spread but doesn’t know where. It may also be useful in checking lymph nodes for cancer before they are removed.

What are the stages of Breast Cancer?

Breast cancer has been divided into four stages; but it is classified into three categories for the purpose of planning treatment:

Early breast cancer: – where the cancer is limited to the breast and lymph nodes in the armpit. The primary aim to treatment in this stage is to cure as well as to conserve the breast. Surgery is the first line of treatment here. Supplementary hormone therapy, chemotherapy and radiotherapy may be required later.

Locally advanced breast cancer: – where the cancer has advanced but is still confined to the breast and the lymph glands. The doctor may first give chemotherapy to shrink the lump and then operate. Hormone therapy and radiotherapy are also mandatory.

Metastatic breast cancer: – where the cancer has spread to other parts outside the breast and lymph glands

Here the treatment cannot cure the cancer but may control it for some time. The treatment involves judicious use of hormone therapy, chemotherapy, radiotherapy and rarely surgery

What are the standard treatments for Breast Cancer?

Treatment is most successful when the cancer is detected early, before it has spread.

Surgery: Breast-conserving surgery (lumpectomy- removes the tumor and surrounding tissue), mastectomy( removes the breast), and lymph node dissection, are different types of surgeries

Radiation therapy: is a highly targeted, effective way to destroy cancer cells in the breast that may stick around after surgery.

Chemotherapy: a cancer treatment in which drugs are given orally/ intravenously to stop the growth of the cells and to kill the cancer cells.

Hormone therapy: It is a very effective treatment against breast cancer that is hormone-receptor-positive

Monoclonal antibody therapy: are with Trstuzumab( Herceptin) and Lapatinib

Often, two or more methods are used in combination with each other.

Surgery:

Surgery forms the mainstay of treatment of breast cancer. It involves removal of the cancerous lump with either preservation or complete removal of the breast.

Lumpectomy: Also called breast conservation therapy, lumpectomy involves removing only the breast lump and some normal tissue around it. Radiation treatment is often given for about 6 weeks after this type of surgery. If chemotherapy is going to be used as well, the radiation may be postponed until the chemo is finished.

Partial (segmental) mastectomy : This surgery involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy.

Simple or total mastectomy: In this surgery the entire breast is removed but not the lymph nodes under the arm or muscle tissue from beneath the breast.

Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm.

Radical mastectomy: This is extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because of disfigurement and fewer side effects.

How is breast reconstruction done?

There are various re-constructive plastic surgery procedures that can reconstruct the breast mound. The surgery involves utilisation of your muscle on the back or abdomen to reconstruct a breast. Breast reconstruction can also be done by implantation of’ silicon prosthesis’.

It is possible to have artificial breast (prosthesis). These prostheses can either be worn externally or a special type of prosthesis can be surgically implanted beneath the skin so as to give the mound

What are the complementary therapies which can help in the healing process?

Relaxation exercise

Meditation

Psychological counselling

Support of family and colleagues

Is breast size a risk factor for breast cancer?

It is proved that greater the breast tissue, greater is the area for the cancer to develop and higher risk for development of breast cancer. It is always seen that most cancers develop at outer rim of the breast due to more tissue mass.

Is the risk of having breast cancer present if either parent’s side have it?

If anyone from the paternal side has breast cancer, there is no chance of developing breast cancer. The risk doubles if a first degree relative (mother > or sister) suffers from it. If more than two first degree members suffer, the risk increases to 50 times.

Do birth control pills cause Breast cancers?

30-40 % risk is seen in girls under the age of 18 who regularly use this method of contraception

HRT used by post -menopausal women increases the risk (63%) of development of breast cancer.

Does wearing an under-wired bra increase the risk of getting breast cancer?

It does not cause breast cancer but women who wear ill-fitting bras may get fat necrosis not cancer.

How is Breast cancer prevented?

Breast cancer can be prevented by the following measures:

Having your first child between 20 -25 years and second before 28 years

Do breastfeeding for a year and maintain healthy diet and weight

Abstain from alcohol

Regular self- examination of the breast for lumps.

If there is a positive family history of breast cancer, after 30 years, regular mammography should be conducted

Does getting annual mammogram increase the risk of cancer?

It does expose the patient to radiation but in a very negligible amount. It is advisable to get routine physical check- ups after the age of 50 years, once in two years for prevention.

Do only women get breast cancers?

No men get it too. Data has shown that for every 100 women diagnosed with breast cancer, one male is diagnosed too.

What is the latest development in Breast cancer treatment?

Some drugs which cancer patients used to take are being developed for taking by women who have breast cancer for prevention of breast cancer.

Oncoplasty is a procedure which is being developed for reconstructing the breast after mastectomy using woman’s own healthy breast tissue

Trastuzumab is a drug under pipeline for reducing the risk of recurrence

A Testimonial from a Breast Cancer Patient to Dr Nanda & Nova Clinic, Koramangala

I was diagnosed with breast cancer in February 2013 and was advised surgery immediately. It was suddenly a bolt out of the blue. A friend advised me to go for a second opinion and suggested that I meet Dr. Nanda Rajneesh at NOVA Superspeciality clinic, Koramangala.

Although I live near Koramangala, I was not aware of the clinic. I followed my friend’s directions and located it. As I entered the clinic, I was very impressed by the clean, aesthetic interiors and cordial and polite staff at the reception. I had no idea that it was a clinic meant for surgery.

I took an appointment and met Dr. Nanda at the clinic. I took an immediate liking to her and when she offered to perform the surgery at the clinic, I readily agreed as I have a mortal fear of big hospitals.

I was totally relaxed on the day of the surgery as I trusted that I was in very competent hands. The staff in the operating theatre was very kind and gentle. I felt no discomfort prior to or post surgery. The entire procedure was performed so smoothly. Although I could have been discharged on the same day, I requested to stay overnight. The staff on night duty checked on me regularly.

After surgery, I had to visit the clinic for dressing which was done so deftly by Dr. Nanda and her wonderful team of nurses. I would like to make a special mention of Sr.Ponds with a kind and re-assuring smile who did my dressing regularly for almost a month.

Dr. Nanda herself is a gem of a person. She helped me put away all my fears and doubts aside and face the situation with confidence. She is my oncologist, friend and support during this trying period.

Finally, my experience at NOVA Superspeciality Clinic, Koramangala has been very satisfying. I would recommend it to any of family or friends if they require visiting medical specialists or have to undergo surgery.