HEALTH LIBRARY

DAILY HYGIENE

Proper hand washing

• Wash the front and back of your hands with soap and warm water.
• Clean under your fingernails and between your fingers.
• Rinse and dry your hands with a clean towel.

- Wash your hands frequently

• After using the restroom
• Before and after eating
• Before and after preparing food
• Before and after holding infants, young children and pets

- Shower- moisturize your skin after showering

- Clean the rectal area thoroughly after bowel movements

- Take care of your chemo port/ central line

• Remove the dressing after 48 hours, after having bath with soap and water
• Avoid unnecessary touching or movement of the port.
• Keep the area clean and dry to prevent infection.
• Hand hygiene should be done before touching the port area.
• Clean the port area with lukewarm water and normal saline
• After completing your chemotherapy, the needle has to be removed, in case it’s not removed please report in day care for its removal

- Perform gentle mouth care (before and after food)

• Rinse with the solution prescribed
• Use toothpaste as tolerated
• Use a very soft toothbrush to gently clean

- Perform deep breathing exercises (avoid Kapalbharti) 

- Protect your skin from sunlight exposure.

• Wear clothing to protect your skin from sunlight

- Wear a face mask

• When your white blood cell count is low
• When you leave your home to outside road or gathering
• When the housekeeper is cleaning your room

 FOOD SAFETY

Safe food handling will help you avoid foodborne illness. The following are critical points for safe food preparation 

- Cleaning Hands and Surfaces

• Wash hands with warm water and soap 
• Before meal preparation.
• After handling the garbage
• Wash cutting boards, dishes, utensils, and countertops
• Clean lids before opening cans

- Storing Food

• Know how long to keep foods in the refrigerator
• Eggs: 7 to 14 days
• Fruits and vegetables: 4 days
• Milk: 2 days
• Discard leftovers that have been kept at room temperature for greater than 2 hours
• Discard leftovers that have been refrigerated greater than 3 days

- Preparing Food

• Wash with water even those with peels that won't be eaten. Scrub and brush fruits and vegetables to remove excess dirt.
• All meats, poultry and seafood must be thoroughly cooked (Avoid Raw Foods)
• All eggs should be cooked until both white and yolk are set and not runny.
• It is ok to use a barbecue grill if the grill is clean and the food and meat are cooked to well done.
• Do not use a microwave to cook meat, fish, poultry or eggs.
• Eat meals within one hour of preparation.
• Bring leftover soups, sauces, and gravies to a rolling boil before serving.

- Avoid foods that may contain a large number of harmful germs    
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• Avoid stale, blemished, damaged, pre-cut, or mouldy produce
• Avoid fast food, take out or restaurant food
• Acceptable Drinking Water - boiled water (boiled for 2 minutes) or Bottled Water/ filtered water by reverse osmosis or distillation (RO)

- Foods to Avoid When You Have Diarrhea

Diarrhea is a common problem after chemotherapy. It is important to avoid foods that can make diarrhea worse. In general, try to do the following: 

• Avoid uncooked vegetables, fruit and whole grains, foods and fluids that are greasy and spicy. 
• Avoid caffeinated beverages
• Avoid milk
• Eat small, frequent meals.
• Drink plenty of fluids
• Eat foods that have bulk stools such as oatmeal, bananas, cooked carrots, rice, noodles, well-cooked eggs, and custard apple.
• Eat rice and curd

- How to Deal with Poor Appetite?

A poor appetite is common but getting adequate nutrition is key to your recovery. In fact, you need more protein and calories for your body to heal after CHEMOTHERAPY. The following strategies may be helpful:
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• Small, frequent meals, for example, cat 5 meals a day or cat meals about 3 hours apart.
• Do not skip meals and snacks, even though you may not be hungry.
• Avoid being around during food preparation if the smell of food bothers you.
• Carry your own food and a beverage with you when you are travelling

WHAT TO DO WHEN YOU HAVE MOUTH SORES

 - Do:

• Avoid very cold or very hot foods and beverages.
• Soften or moisten food by dipping them in liquid or taking a sip of a beverage with food.
• Choose soft foods such as bananas, pears, mashed potatoes, scrambled eggs, custards, creamy soups and cereals, yoghurt, ice cream, sherbet, upma, Sabudana.

- Don't:

• Use spices.
• Drink citrus or acidic beverages which can be irritating and may burn or sting.
• Eat hard, dry or fried foods, raw vegetables and foods with seeds and tough skins.

- Avoid Exposure to Microorganisms

• Avoid anyone who is ill with cold, flu or other infections
• Wear face mask
• Do not clean animal cages, empty litter boxes or handle animal faeces of any kind 
• Do not do any gardening or caring for plants in the home
• Do not vacuum or dust (leave the room during vacuuming and dusting)
• Avoid construction sites
• Do not use rectal thermometers, rectal medications (suppositories) or enemas
• Do not have any invasive procedures by a dentist, or physician without first checking with the team

Exercise

- Avoid inactivity and return to normal daily activities as soon as possible after diagnosis and treatment.

- Exercise for up to 30 minutes (low intensity) for 5 times each week.

WARNING SIGNS OF CATHETER OR PORT PROBLEMS

Contact your doctor immediately if:

- The area becomes red, swollen, painful, bruised, warm or itchy

- There is a lot of bleeding

- You get a fever.

- Any fluid leaks out

- You have shortness of breath or dizziness.

- Fever or chills:

• Temperature > 101°F or 38.3°C or
• Temperature of 100°F or 38°C sustained over one hour

- Cold Symptoms

• Cough
• Sore throat
• Green or yellow sputum
• Runny nose

- Shortness of breath

- Any area of your skin becomes warm to touch, red, painful or swollen

- Any new skin changes or rashes

- Nausea or vomiting that persists and prevents you from taking in fluids or food

- Bleeding, especially:

• From your mouth, nose, gums, under the skin (bruising)
• Blood in your urine, stool or sputum
• Prolonged or heavy vaginal bleeding

- Change in bowel bladder habit

• Difficulty emptying your bladder
• Pain or burning during urination
• Constipation, pain during passage of stool, blood with stool
• Diarrhea - more than 4-5 loose bowel movements in 24 hours

- Neurological sign/ symptoms

• Unusual headaches
• Double or blurred vision
• Changes in your thinking (confusion, showed thinking, excessive sleepiness)

What is lung cancer? 

Lung cancer is an abnormal growth of cells in the lungs. Lung cancer may eventually spread to other parts of the body if not discovered and treated early. 

What are the risk factors for lung cancer?

Smoking is the single greatest avoidable risk factor for cancer. It is responsible for one in four of all deaths from cancer. Smoking causes around 90% of lung cancers. There are multiple benefits from quitting. Once you stop smoking, your risk of lung cancer starts to go down. 10 years after you've given up, your lung cancer risk is about half that of a smoker.

What causes lung cancer? 

The most significant cause of lung cancer is cigarette smoke (National Cancer Institute). Roughly 85% of lung cancers are diagnosed in former or current smokers; other cases may be caused by environmental exposure to materials like radon, asbestos or uranium, or second hand smoke. Genetics can also play a role. 

I have been smoking for many years? Why should I stop smoking now?

Lung cancer takes years to develop. The risk increases with each year of smoking, and with each cigarette smoked per day. Stopping smoking will reduce the risk of lung cancer developing as well as reduce the likelihood of developing heart and lung problems. Smoking also increases the risk of other diseases, such as chronic lung disease, heart disease, stroke and other cancers such as head and neck cancers. Smoking can also harm your spouse and family members.

Do non-smokers get lung cancer?

Yes, non-smokers can get lung cancer, but the risk is much lower than in smokers. There are factors other than smoking that increase a person's risk of getting lung cancer. Breathing in other people's smoke, exposure to radon, asbestos, air pollution, certain chemicals in the workplace, and a personal or family history of lung cancer are also risk factors for lung cancer.

What lung cancer risks are associated with second hand smoke?

Second hand smoke contains twice as much tar and nicotine per unit volume than smoke inhaled directly from a cigarette. More significantly, second hand smoke contains three times more cancer-causing compounds and 30 times more carbon monoxide than first hand smoke. Second hand smoke is responsible for thousands of cases of lung cancer and asthma each year.

Why is early lung cancer screening important? 

It is important because lung cancer has no symptoms in its early stages. Over 85% of men and women diagnosed with lung cancer today are diagnosed in later stages, after symptoms have occurred and when there is very little chance of cure. Consequently, approximately 95% of people diagnosed each year die from the disease.

What are the most common symptoms of lung cancer?

This is a tricky one because sometimes there aren't any symptoms of lung cancer. One in four people don’t even have symptoms when their lung cancer is advanced. In other people, symptoms that may suggest lung cancer can include:

• Shortness of breath
• Coughing that doesn't go away
• Wheezing
• Coughing up blood
• Chest pain
• Fever
• Weight loss

What are the tests for lung cancer? 

There are a number of tests that can be used to detect lung cancer. However, most tests miss many early cancers, and are often ordered only after the patient has started having symptoms. Traditional lung cancer tests include:

• Chest x-ray
• Sputum Cytology (analyzing cells in mucus)
• Bronchoscopy (using a tube through the mouth to look at the lungs with a tiny camera).

To confirm that a person has lung cancer, the doctor must examine fluid or tissue from the lung. This is done through a biopsy - the removal of a small sample of fluid or tissue for examination under a microscope by a pathologist. A biopsy can show whether a person has cancer. A number of procedures may be used to obtain this tissue.

 Bronchoscopy -- The doctor puts a bronchoscope - a thin, lighted tube into the mouth or nose and down through the windpipe to look into the breathing passages. Through this tube, the doctor can collect cells or small samples of tissue.

 Needle Aspiration - The doctor numbs the chest area and inserts a thin needle into the tumor to remove a sample of tissue.

 Thoracentesis - Using a needle, the doctor removes a sample of the fluid that surrounds the lungs to check for cancer cells.

 Thoracotomy - Surgery to open the chest is sometimes needed to diagnose lung cancer. This procedure is a major operation performed in a hospital.

 PET-CT– An imaging test that uses a radioactive substance (called a tracer) to look for cancer cells in the lungs.

What are the standard treatments for lung cancer?

Surgery is an operation to remove the cancer. Depending on the location of the tumour, the surgeon may remove a small part of the lung, a lobe of the lung, or the entire lung.

Conventional chemotherapy uses anti-cancer drugs to kill cancer cells throughout the body. Doctors use chemotherapy to control cancer growth and relieve symptoms. Anti-cancer drugs are given by injection; through a catheter, a long thin tube temporarily placed in a large vein; or in pill form.

 Targeted agents and Immunotherapy are a newer class of drugs that are designed to act against specific weaknesses in cancer cells or surrounding supportive tissues, such as blood vessels. These drugs can also be taken by pill or by IV. They are most effective in cancers with specific changes in their genes.

Radiation therapy uses high-energy beams to kill cancer cells and shrink tumors. An external machine delivers radiation to a limited area, affecting cancer cells only in that area. Doctors may use radiation therapy before surgery to shrink a tumor or after surgery to destroy any cancer cells remaining in the treated area.

What are the treatment options for the lung cancer that has spread to other parts of the body?

Almost 60-70% of patients have advanced lung cancer. Additional tests on the biopsy specimen to subtype the cancer may help determine whether chemotherapy or targeted therapy is more suitable. The treatment goal in such cases is to enhance the quality of life, reduce symptoms, and prolong survival. Currently, patients in this category are not only living longer but also enjoying a better quality of life. 

What types of surgery are used to treat lung cancer?

Depending on the extent of the cancer, the surgeon may decide to remove part or all of the lung. Taking out a part of the lobe of a lung is called a segmental or wedge resection. If a lobectomy is performed, an entire lobe of the lung is removed; this is usually the preferred surgery for lung cancer if it can be done. A pneumonectomy involves the removal of an entire lung, while a sleeve resection removes only the part of the bronchus with cancer, with the lung then reattached to the remaining part of the bronchus

After a lung is removed, what happens to the space that's left in the chest?

Space left after surgery is filled up with body fluid and scar tissue and the other lung usually expands. Until this happens, there may be a feeling of emptiness on the side of the operation.

Can I breathe and live normally if I have a lung removed?

Most likely, depending on your lung function before the surgery. The removal of one or two lobes may limit strenuous physical exercise, but you should otherwise be able to breathe and live normally. If you have an entire lung removed, you may experience shortness of breath during exertion, but at rest, your breathing will be normal. Breathing exercises will help you in adapting to this.

How can lung cancer be prevented?

The best way to prevent lung cancer is to avoid smoking and to avoid breathing in other people's smoke. If you smoke, quit. While the risk for former smokers remains elevated when compared to a non-smoker, it continues to fall with each year of smoking cessation. In fact, 10 years after you've given up, your lung cancer risk is about half that of a smoker.

There is some evidence that eating a healthy diet rich in fibre, fruit and vegetables may help reduce the risk of lung cancer. Also, as per research, higher levels of physical activity may lead to a 20-40% reduction in lung cancer risk.

What is stomach? Where is it located?

The stomach is a muscular bag-like organ that lies in the upper left side of the abdomen below the main muscle of breathing – the diaphragm. The stomach connects the food pipe to the small intestine. It stores food for the first 2-4 hours after eating. In these two hours, the food is acted upon by acid produced by the stomach and by enzymes from the mouth that have traveled down along with the food.  The stomach muscles then contract to help breakdown the large portions of food into smaller pieces so that once the food enters the small intestine, the enzymes there can better act to digest the food. Major organs lie around the stomach including the liver, spleen, and pancreas. As shown in the diagram, the stomach is divided into 3 parts and cancers may arise in any of thee parts. The type of surgery will depend on the location of the tumour.

Why have I developed stomach cancer?

Development of stomach cancer cannot be attributed to any single factor. There are multiple factors suggested to be responsible for causing stomach cancer. These include diet, Helicobacter pylori (H. pylori) infection, smoking and long-term acid reflux. High intake of salted, pickled or smoked foods, as well as dried fish and meat and refined carbohydrates significantly increase the risk of developing stomach cancer. H. pylori is a microbe associated with the risk of developing stomach cancer if not treated. However, patients may develop these cancers even without any of these risk factors being present.

What are the symptoms of stomach cancer?

The presentation of stomach cancer is very non-specific. Loss of appetite, heart-burn, difficulty in swallowing, loss of weight are some of the symptoms associated with the cancer. Unexplained anaemia is another form of presentation and hence such patients need to undergo endoscopy to rule out stomach cancer. Vomiting is another sign of stomach cancer if associated with the other symptoms mentioned above. Patients, who present with heart-burn and reflux for the first time after the age of 40 years, need to undergo an endoscopy to rule out stomach cancer amongst other causes. Lump in the abdomen and back pain are late signs of the disease and usually indicate an advanced disease.

What investigations will I be subjected to?

The best investigation to diagnose stomach cancer is endoscopy with a biopsy of the tumour. A computed tomography (CT) scan of the abdomen and pelvis will help to support the diagnosis of the cancer as well to determine whether the cancer is at an early stage or whether it has spread to the lymph nodes, liver or other organs and if the stomach cancer has infiltrated the surrounding organs. Serum CEA (a blood test) is a marker used in stomach cancer. It is of more use if its value is high as this indicates that the patient’s cancer may be advanced, thereby adding to other investigations when deciding other treatment options. Liver function tests, X-ray of the chest, etc. are other investigations to decide the stage of the disease. If an operation is being planned, some more tests may be necessary to decide fitness of the patient for general anaesthesia.

Are there different types of stomach cancer?

Yes, there are different types of stomach cancer depending on the type of cell / tissue from which the cancer is arising. Adenocarcinoma is one of the common types of stomach cancer. There are a few rare types of cancer affecting the stomach including gastrointestinal stromal tumours (GIST), lymphoma and leiomyoma. The treatment depends on the type of cancer.

At what stage is the cancer?

Accurate staging of the cancer is based on histopathology and will be possible only after surgery. Based on clinical and radiological findings, stomach cancer can be broadly classified into

Stage 1 / Early cancer – cancer only within the stomach with no spread of disease outside of it

Stage 2 or 3 / Locally advanced cancer – when the cancer appears large and or/ invading other surrounding organs, with enlarged lymph nodes

Stage 4 / Metastatic – when the cancer has spread far from the stomach, for eg to the liver, lungs, brain, ovary, etc. These patients also usually have some fluid building up in the abdomen.

If the cancer comes back after initial treatment, it is known as recurrent cancer.

Now that I have been diagnosed to have stomach cancer, how will I be treated?

A team of multi-disciplinary specialists including a surgeon, medical gastroenterologists, radiation and medical oncologist, radiologist and pathologist will discuss the treatment that would be best for you. The treatment is usually decided based on the stage of the disease and in early cancer the optimal treatment will be surgery. In locally advanced tumors, the treatment will be with chemotherapy first. If the cancer responds well and shrinks, surgery may be offered after chemotherapy.

In metastatic / advanced tumours, the treatment is usually chemotherapy or treatment directed towards controlling the symptoms (symptomatic care).

In some patients, surgery may have to be performed even if the disease is locally advanced especially if they develop complications of the cancer such as bleeding that is causing severe anaemia requiring blood transfusions, of if the stomach is obstructed and the patient cannot retain anything they eat or drink due to profuse vomiting, or if the cancer has resulted in a hole in the stomach with leakage of stomach contents into the abdomen.

Patients with lymphoma of the stomach will be treated only with chemotherapy unless they develop the above mentioned complications.

Which kind of surgery is done for stomach cancer?

The type of surgery depends on the location of the cancer and extent. Removal of a portion of the stomach is called gastrectomy. There are curative and palliative gastrectomies.

Curative surgeries are done with an aim to remove the entire cancer with a margin of normal tissue around and all the lymph nodes involved (lymphadenectomy). These include:

• Distal / Subtotal gastrectomy for tumours located in the lower portion of the stomach
• Proximal or Total gastrectomy for tumours located in the upper portion of the stomach
• Wedge resection for GIST tumours
• Lymph nodes around the stomach are removed at the same time to check if cancer cells have spread into them.
• Laparoscopic / key-hole surgery has been used in some centres around the world to perform distal gastrectomy. However, its value in terms of ability to completely remove the cancer afflicted stomach and the lymph nodes as compared to open surgery are still unclear at the present time.
• Palliative surgery is done for symptom control and not with intent for cure. This is because these surgeries are done in patients with advanced disease who have developed complications of the cancer (mentioned above). In an obstructing advanced cancer, only a bypass of the block (gastrojejunostomy) may be possible. Sometimes, even if a patient is taken up for emergency surgery due to a complication of the cancer, no resection may be possible if the disease is very advanced and the abdomen will just have to be closed without any further surgical intervention.

In some patients with an obstruction who are not fit for surgery, endoscopic stenting of the tumour may be attempted.

Are there any alternatives besides surgery?

Till date, surgery is the only proven curative option for stomach cancer.

How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anaesthetist’s advice regarding continuation of medications if you are on any. A high protein diet is preferred to improve nutrition.

How major is the surgery? What are the possible complications?

Gastrectomy with lymphadenectomy and other gastric surgeries are deemed as major surgeries with a risk of complications (4-10%) and a very small risk of death (<2>

The complications of gastrectomy (removal of the stomach and lymph nodes and joining back (anastomosis) the healthy bowel / intestine) include:

• Leak of anastomosis
• Bleeding from the anastomosis
• Prolonged vomiting

Will I need any further treatment after surgery?

The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymph nodes are positive and your general condition is good enough then you may be referred to the medical (GI) oncologist for consideration for chemotherapy or targeted therapy in some cases.

What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival depends on the stage of the disease. The average 5-year survival after curative surgery for stomach cancer is 25-35%. This means that 25-35 out of a 100 people with stomach cancer will survive and be disease-free at the end of 5 years. As of date there is no foolproof way of predicting which patients will have recurrence and which patient will not.

Are there any special precautions I need to take to prevent cancer from coming back?

There are no proven precautions, but it is logical to exercise regularly, avoid using tobacco and alcohol and maintain a good diet. Following gastrectomy, since the size of the stomach is now reduced, you should eat smaller meals at regular intervals.

How frequently should I follow up after surgery?

After completion of treatment you will be advised to follow-up once in 3-4 months in the first 2-3 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow up will be once a year. During each follow-up you will be asked to do certain blood tests, especially CEA. You may also be advised to get an ultrasound of the abdomen done.

What is the Rectum? Where is it located?

The rectum and anal canal forms the lower end of the body’s digestive system. The digestive system is made up of the esophagus,

stomach, small and large intestine. The main part of the large intestine is called the colon, which is about 150 cm long. This is split into four sections: the ascending, transverse, descending and sigmoid colon. Some water and salts are absorbed into the body from the colon. The colon leads into the rectum (back passage), which is about 15 cm long and is contained in the pelvis. Within the pelvis the rectum is located just in front of the sacrum (i.e. the lower portion of the backbone) with the urinary bladder and prostate in front of it in males. In females, the uterus and vagina lie in between the urinary bladder in front and the rectum behind. The rectum stores feces (stools) before they are passed out from the anus.      

Why have I developed rectal cancer?

Development of rectal cancer cannot be attributed to any single factor. There are certain risk factors which increase the chance of developing rectal cancer. Risk factors include: 

• Age – Rectal cancer is more common in older people (50 and above). There has been reported to be an increased incidence of rectal cancer in young Indians. It is unclear at the current time if such an incidence is just a relative increase owing to our larger population as compared to Western countries. Irrespective of this, the importance of awareness that even the young may be afflicted with rectal cancer needs to be born in mind and they should seek medical attention if they encounter the symptoms listed below
• A person with one or more family members with bowel cancer
• A personal history of cancer of the colon, ovary, endometrium or breast
• A history of ulcerative colitis (conditions of the colon) for more than 8-10 years
• Obesity
• Lifestyle factors – little exercise, drinking lot of alcohol, and long-term use of tobacco
• Certain hereditary conditions such as familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer (HNPCC, Lynch syndrome)

However, patients may develop these cancers even without any of these risk factors being present.

What are the symptoms of rectal cancer?

 The symptoms of rectal cancer include but are not limited to the following:

• A change in bowel habits – unexplained diarrhoea or constipation
• Blood (either bright red or very dark) in the stool
• Feeling that the bowel does not empty completely after a bowel motion
• Frequent gas pains, bloating, fullness or cramps
• Unexplained weight loss
• Feeling very tired.

All patients above the age of 40 years are advised to have a faecal occult blood test every 6 months. If positive, the patent is sent for a colonoscopy. It is advisable for adults above the age of 40 years, especially those with a family history of bowel cancer, to get themselves tested for faecal occult blood by visiting their family physician.

Certain benign conditions of the lower rectum and anus like piles (haemorrhoids), anal fissure (wound in the anal canal) etc. can also present with symptoms similar to rectal cancer. It is important to rule out rectal cancer in patients with these benign conditions as sometimes both can be present. If the cancer spreads to other parts of the body, various other symptoms can develop. The symptoms depend on where it has spread to. All the above symptoms can be due to other conditions, so tests are needed to confirm rectal cancer.

What investigations will I be subjected to?

The best investigation to diagnose rectal cancer is endoscopy with a biopsy of the tumour. As cancer of the rectum may be associated with the simultaneous presence of tumours in another portion of the large intestine, colonoscopy should be performed to evaluate the entire large bowel. A computed tomography (CT) scan or Magnetic resonance imaging (MRI) of the abdomen and pelvis will help to support the diagnosis of the cancer as well to determine whether the cancer is at an early stage or whether it has spread to the lymph nodes, liver or other organs and if the rectal cancer has infiltrated the surrounding organs. Serum CEA (a blood test) is a marker used in colon and rectal cancer. It is of more use if its value is high as this indicates that the patient’s cancer may be advanced, thereby adding to other investigations when deciding other treatment options. Liver function tests, X-ray of the chest, PET-CT scan etc. are other investigations to decide the stage of the disease. If an operation is being planned, some more tests may be necessary to decide fitness of the patient for general anesthesia. 

Are there different types of rectal cancer? 

Yes, there are different types of rectal cancer depending on the type of cell / tissue from which the cancer is arising. Adenocarcinoma is the most common type of rectal cancer. Gastrointestinal stromal tumours (GIST), lymphoma and leiomyoma are some of the less common types of rectal cancers. The treatment depends on the type of cancer.

Is cancer of the anal canal similar to rectal cancer?

Although the anal canal is situated below the rectum and forms the last 4cm of the body's digestive system, cancer of the anal canal is quite different from rectal cancer. The most common form of anal cancer is squamous cell carcinoma although other forms like melanoma also occur in this region. These cancers tend to spread to the lymph nodes in the groin unlike rectal cancer which spreads in an upward direction towards the abdominal lymph nodes. Unlike rectal cancer, the majority of patients with anal cancer are controlled with a treatment combination of radiation and chemotherapy. However patients who are not controlled with this treatment may require an abdomino-perineal resection. (details of this procedure have been mentioned below)

At what stage is the cancer?

Pre-operative investigations give some information about the stage of the disease, however the most accurate staging of rectal cancer is based on histopathology and is possible only after surgery when the removed cancer and the draining lymph nodes are examined by the pathologist.

Rectal cancer can be broadly classified into: 

Stage 1 / Early cancer – cancer only within the rectum with no spread of disease outside it.

Stage 2 or 3 / Locally advanced cancer – when the cancer appears large and/or invading other surrounding organs, with enlarged lymph nodes.

 Stage 4 / Metastatic – when the cancer has spread far from the rectum e.g. to the liver, lungs, etc. These patients also usually have some fluid building up in the abdomen. It is usually not possible to cure stage 4 cancer. Treatment is intended to reduce symptoms and improve the patient’s quality of life.

If the cancer comes back after initial treatment, it is known as recurrent cancer.

Now that I have been diagnosed to have rectal cancer, how will I be treated?

A team of multi-disciplinary specialists including a surgeon, medical gastroenterologists, radiation and medical oncologist, radiologist and pathologist will discuss the treatment that would be best for you. Different types of treatment are available for patients with rectal cancer. Four types of standard treatment are used:

•  Surgery
•  Chemotherapy
• Radiation therapy
• Targeted Therapy

The type of treatment administered depends on the stage of disease in each patient. For early stage disease surgery is usually offered first. Following the operation and depending on the pathology report, additional treatment in the form of radiation, or chemotherapy or both could be required.

Patients with locally advanced rectal cancer tend to do better with a combination of radiation and chemotherapy prior to surgery and this order of treatment i.e. Chemotherapy ± radiation followed by surgery, is usually offered wherever possible. A gap of at least six weeks is required between radiation and surgery. Additional chemotherapy may be required following surgery in some patients.

Patients with metastatic disease need chemotherapy with or without targeted therapy. Surgery may also be required in these patients at some point. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells either by killing the cells or stopping them from dividing. Radiation therapy is a cancer treatment that uses high energy X-rays or other types of radiation to kill cancer cells or to keep them from growing. Targeted therapy uses drugs or substances to identify and attack specific cancer cells without harming normal cells.

Which kind of surgery is done for rectal cancer?

The type of surgery largely depends on the location of the cancer from the anal opening.

For tumours very close to the anus, the anal canal cannot be preserved and the entire rectum and anus needs to be removed to eliminate all cancerous tissue. The place where the anus was, is closed permanently and the patient is then given a permanent stoma (i.e. an opening in the skin through which the intestine empties its contents into a bag) in the left lower part of the abdomen. This operation is known as an abdomino-perineal resection (APR).

In patients where the cancer does not extend right upto the anus, the portion of rectum with the cancerous tissue is removed and the descending colon is joined to the remaining rectum to preserve the normal intestinal continuity. This operation is known as an anterior resection. Patients in whom an anterior resection is performed sometimes need a temporary stoma to divert the stools until the area where the intestine was joined has completely healed.

For some tumours which are very close but do not reach the anus, the decision between an abdomino-perineal resection and anterior resection will have to be made during the operation. The patient needs to be prepared for both procedures before surgery.

If I have a temporary stoma when will it be closed?

The temporary stoma is usually closed after complete healing of the area where the intestine was joined. This usually takes 6 weeks to 3 months. However, if the patient requires additional treatment after surgery in the form of chemotherapy or radiotherapy or both, the temporary stoma is only closed after all treatment is completed. This may take up to a year in some patients.

Do I need another operation to close the stoma?

Yes, another operation will be required to close the stoma. This is also a major operation but not quite as major as the first one where the cancer was removed. 

Will I be able to lead a normal life after rectal cancer surgery?

If the cancer is controlled with treatment i.e. surgery, radiation and chemotherapy, then patients usually lead a normal life following rectal surgery. However, depending on the procedure performed a few changes will have to be made. Patients having an APR will have to learn how to manage their stoma. There is a dedicated stoma management team to help these patients. In patients receiving an anterior resection, as the rectum is removed there is no space for the body to collect the stools. Therefore, immediately after the surgery patients will experience more frequent bowel motions and may have some difficulty in controlling the passage of stools. However, over time the body adjusts and the frequency of stools decreases and continence improves.

What is laparoscopic surgery? Can it be used for rectal cancer?

Laparoscopy, also known as key hole surgery, is a surgical technique where the operation is performed through small holes in the abdominal wall using specialized instruments. Some patients also have an incision in the abdomen but this is usually of smaller size as compared to conventional open surgery. Rectal cancer surgery can be performed laparoscopically but must be done at centres equipped with the instruments and expertise for it. Laparoscopy has been shown to offer benefits to the patients in terms of less pain, a faster return of bowel function, and a shorter hospital stay. However every laparoscopic procedure has the possibility of being converted to the conventional open approach if the entire procedure cannot be completed laparoscopically.

Can patients have sexual dysfunction following rectal cancer surgery?

As the rectum lies in the pelvis, it lies very close to the nerves that supply the sexual organs. These nerves are very fine and are at risk of injury during surgery. Although every attempt is made to safeguard these nerves some patients do experience sexual dysfunction in the form of impotence (i.e. failure of erection), retrograde ejaculation (i.e. failure of ejaculation) or dyspareunia (painful sexual intercourse in females). In some of these patients the sexual function improves over time but some patients do have persistent sexual dysfunction that may be life-long.     

Are there any alternatives besides surgery?

Till date, curative surgery offers the best results in terms of local control and overall survival for rectal cancer.

How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anaesthetist’s advice regarding continuation of medications if you are on any. A high protein diet is preferred to improve nutrition.

How major is the surgery? What are the possible complications?

Rectal surgeries are deemed as major procedures with a risk of complications (<1>

The complications of rectal resection (removal of the rectum and lymph nodes and joining back (anastomosis) the healthy bowel / intestine) include:

• Leak of anastomosis
• Bleeding from the anastomosis
• Bladder complications
• Sexual dysfunction.

For how long do I stay in the hospital?

In an uncomplicated case, hospital stay after surgery is 7-10 days. This may be longer when there are complications. 

Will I need any further treatment after surgery?

The decision about treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymph nodes are positive and your general condition is good enough then you may be referred to the medical (GI) oncologist for consideration for chemotherapy, radiotherapy or both. The aim of treatment after surgery is to get rid of any remaining cancer cells which may not be seen on scans thereby reducing the chance of cancer coming back in the future.

What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival depends on the stage of the disease. The average 5-year survival for all stages after curative surgery for colorectal cancer is between 40-75?pending on the stage of the cancer. To-date, there is no fool-proof way of predicting which patients will have recurrence and which patient will not.

Are there any special precautions I need to take to prevent cancer from coming back?

There are no proven precautions, but it is logical to exercise regularly, avoid using tobacco, drink alcohol in moderation and maintain a good diet. 

How frequently should I follow up after surgery?

After completion of treatment you will be advised to follow-up once in 3-4 months in the first 2 years. Then the frequency will be reduced to once in 6 months for the next 3 years. Subsequent follow up will be once a year. During each follow-up you will be asked to do certain blood tests, especially CEA. You may also be advised to get an ultrasound of the abdomen and colonoscopy. If you have any problems or new symptoms between your appointments, see your doctor sooner. Colonoscopy can show recurrence of polyps or cancer in the colon. In addition to checking for cancer recurrence, patients who have had colon cancer may have an increased risk of cancer of the prostate, breast and ovary. Therefore, follow-up examinations should include these areas.

What is Oesophagus Cancer? 

Oesophagus, also known as the food pipe is a muscular tube measuring 20-25 cm long and 2-3 cm wide that serves as a conduit for moving food and drink from the mouth to the stomach. The oesophagus  is divided into 3 parts and cancers may arise in any of thee parts. The type of surgery and treatment will depend on the location of the tumour. Oesophageal cancer is the 6^th most common cancer in India.

Cancers that start in the area where the oesophagus joins the stomach (the gastro-esophageal  junction) including about the first 2 inches of the stomach tend to behave like esophageal cancers; they are grouped with esophageal cancers.

Why have I developed Oesophagus cancer?

Development of oesophageal cancer cannot be attributed to any single factor. There are multiple factors suggested to be responsible for causing oesophageal  cancer. These include diet,  smoking, long-term acid reflux, alcohol /tobacco consumption and obesity.  High intake of salted, pickled or smoked foods, very hot drinks, as well as dried fish and meat and refined carbohydrates significantly increase the risk of developing oesophageal cancer.. However, patients may develop these cancers even without any of these risk factors being present.

What are the symptoms of oesophagus cancer?

The presentation of oesophageal cancer  can be with any  of the following symptoms : Difficulty in swallowing food (dysphagia), Unexplained weight loss, Worsening indigestion or heartburn, Tightness or pain in the chest, Cough or hoarseness of voice. Patients, who present with heart-burn and reflux for the first time after the age of 40 years, need to undergo an endoscopy to rule out cancer amongst other causes. Lump in the abdomen and back pain are late signs of the disease and usually indicate an advanced disease.

What investigations will I be subjected to?

The best investigation to diagnose oesophagus cancer is endoscopy with a biopsy of the tumour. A computed tomography (CT) scan of the abdomen and pelvis will help to support the diagnosis of the cancer as well to determine whether the cancer is at an early stage or whether it has spread to the lymph nodes, liver or other organs and if the stomach cancer has infiltrated the surrounding organs. Liver function tests, X-ray of the chest, etc. are other investigations to decide the stage of the disease. If an operation is being planned, some more tests may be necessary to decide fitness of the patient for general anaesthesia. Endoscopic ultrasound (using an ultrasound probe at the end of an endoscope) helps the doctor to see the extent of growth of tumor into nearby areas as well as to check for enlarged lymph nodes.

Are there different types of oesophagus cancer?

Yes, there are different types of oesophagus cancer depending on the type of cell / tissue from which the cancer is arising. squamous cell carcinoma arises from the stratified squamous epithelial lining of the organ, and adenocarcinoma affecting columnar glandular cells that replace the squamous epithelium. Other types of esophageal cancer are uncommon. The treatment depends on the type of cancer.

At what stage is the cancer?

Accurate staging of the cancer is based on histopathology and will be possible only after surgery. Based on clinical and radiological findings, oesophagus cancer can be broadly classified into: 

Stage 1 / Early cancer – cancer only within the oesophagus  with no spread of disease outside of it

Stage 2 or 3 / Locally advanced cancer – when the cancer appears large and or/ invading other surrounding organs, with enlarged lymph nodes

Stage 4 / Metastatic – when the cancer has spread far from the oesophagus, for eg to the liver, lungs, brain, ovary, etc.

If the cancer comes back after initial treatment, it is known as recurrent cancer.

Now that I have been diagnosed to have oesophagus cancer, how will I be treated?

A team of multi-disciplinary specialists including a surgeon, medical gastroenterologists, radiation and medical oncologist, radiologist and pathologist will discuss the treatment that would be best for you. The treatment is usually decided based on the stage of the disease and in early cancer the optimal treatment will be surgery. In locally advanced tumors, the treatment will be with chemotherapy or chemo-radiotherapy first. If the cancer responds well and shrinks, surgery may be offered after this treatment.

In metastatic / advanced tumours, the treatment is usually chemotherapy or treatment directed towards controlling the symptoms (symptomatic care).

In some patients, a stent may have to be inserted especially if there is difficulty in swallowing leading to vomiting.

Which kind of surgery is done for oesophageal  cancer?

The type of surgery depends on the location of the cancer and extent. Removal of a portion of the oesophagus is called oesophagectomy.

Curative surgeries are done with an aim to remove the entire cancer with a margin of normal tissue around and all the lymph nodes involved (lymphadenectomy).

Lymph nodes around the oesophagus  are removed at the same time to check if cancer cells have spread into them.

Laparoscopic / key-hole surgery has been used in some centres around the world to perform surgery. However, its value in terms of ability to completely remove the cancer and the lymph nodes as compared to open surgery are still unclear at the present time.

Palliative surgery is done for symptom control and not with intent for cure. This is because these surgeries are done in patients with advanced disease who have developed complications of the cancer. Sometimes, even if a patient is taken up for emergency surgery due to a complication of the cancer, no resection may be possible if the disease is very advanced and the abdomen will just have to be closed without any further surgical intervention. In some patients with an obstruction who are not fit for surgery, endoscopic stenting of the tumour may be attempted.

Are there any alternatives besides surgery?

Till date, surgery is the only proven curative option for oesophageal cancer. In some instances, chemo-radiotherapy is effective is squamous cell cancers.

How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anaesthetist’s advice regarding continuation of medications if you are on any. A high protein diet is preferred to improve nutrition.

How major is the surgery? What are the possible complications?

Oesophagectomy with lymphadenectomy is deemed as major surgeries with a risk of complications (4-10%) and a very small risk of death (<2>This means that if 100 people are operated, less than 2 of them have a chance of death. The complications of Oesophagectomy (removal of the oesophagus  and lymph nodes and joining back (anastomosis) the healthy bowel / intestine) include:

• Leak of anastomosis
• Bleeding from the anastomosis
• Prolonged vomiting

For how long do I stay in the hospital?

In an uncomplicated case, hospital stay after surgery is 9-14 days. This may be longer when there are complications.

Will I need any further treatment after surgery?

 The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymph nodes are positive and your general condition is good enough then you may be referred to the medical (GI) oncologist for consideration for chemotherapy or targeted therapy in some cases.

What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival depends on the stage of the disease. The average 5-year survival after curative surgery for oesophagus  cancer is 25-35%. This means that 25-35 out of a 100 people with oesophagus  cancer will survive and be disease-free at the end of 5 years. As of date there is no foolproof way of predicting which patients will have recurrence and which patient will not.

Are there any special precautions I need to take to prevent cancer from coming back?

There are no proven precautions, but it is logical to exercise regularly, avoid using tobacco and alcohol, and maintain a good diet. Following oesophagectomy,  you may need to  eat smaller meals at regular intervals.

How frequently should I follow up after surgery?

 After completion of treatment you will be advised to follow-up once in 3-4 months in the first 2-3 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow up will be once a year. During each follow-up you will be asked to do certain blood tests. You may also be advised to get an ultrasound of the abdomen done.

What is colon? Where is it located?

The colon is a part of the body’s digestive system. The digestive system is made up of the esophagus, stomach, small and large intestine. The main part of the large intestine is called the colon, which is about 150 cm long. This is split into four sections: the ascending, transverse, descending and sigmoid colon. Some water and salts are absorbed into the body from the colon. The colon leads into the rectum (back passage). Major organs lie around the colon including the duodenum, liver, kidney, spleen, and pancreas.

Why have I developed colon cancer?

Development of colon cancer cannot be attributed to any single factor. There are certain risk factors which increase the chance of developing colon cancer. Risk factors include

• Age – colon cancer is more common in older people ( 50 and above)
• A family history of cancer of the colon or rectum
• A personal history of the colon, rectum, ovary, endometrium or breast
• A history of ulcerative colitis or Crohn’s disease (conditions of the colon) for more than 8-10 years
• Obesity
• Lifestyle factors – little exercise, drinking lot of alcohol
• Certain hereditary conditions  such as familial adenomatous polyposis, hereditary nonpolyposis colon cancer (HNPCC Lynch syndrome)

However, patients may develop these cancers even without any of these risk factors being present.

What are the symptoms of colon cancer?

The presentation of colon cancer depends on the site of the tumor. A doctor should be consulted if any of the following occur

• A change in bowel habits
•  Blood (either bright red or very dark) in the stool
• Diarrhea, constipation or feeling that the bowel does not empty completely
• Frequent gas pains, bloating, fullness or cramps.
• Weight loss for no reason.
• Feeling very tired.
• Vomiting

All patients above the age of 40 years are advised to have a faecal occult blood test every 6 months. If positive, the patent is sent for a colonoscopy. It is advisable for adults above the age of 40 years, especially those with a family history of bowel cancer, to get themselves tested for faecal occult blood by visiting their family physician.

Unexplained anemia is another form of presentation. If the cancer spreads to other parts of the body, various other symptoms can develop depending on the site of spread. Colon cancer can also present with complications such as intestinal obstruction, intestinal perforation and bleeding. All the above symptoms can be due to other conditions, so tests are needed to confirm colon cancer.

 What investigations will I be subjected to?

The best investigation to diagnose colon cancer is colonoscopy with a biopsy of the tumour. A computed tomography (CT) scan of the abdomen and pelvis will help to support the diagnosis of the cancer as well to determine whether the cancer is at an early stage or whether it has spread to the lymph nodes, liver or other organs and if the colon cancer has infiltrated the surrounding organs. Serum CEA (a blood test) is a marker used in colon cancer. It is especially useful if its value is high as this indicates that the patient’s cancer may be advanced, thereby adding to other investigations when deciding other treatment options. After curative surgery, its level becomes normal. Thus it is routinely performed at follow-up to help detect recurrence of the cancer. Liver function tests, chest X-ray and or CT scan , etc. are other investigations to decide the stage of the disease. If an operation is being planned, some more tests may be necessary to decide fitness of the patient for general anesthesia.

Are there different types of colon cancer?

Yes, there are different types of colon cancer depending on the type of cell / tissue from which the cancer is arising. Adenocarcinoma is the most common type of colon cancer. Gastrointestinal stromal tumours (GIST), lymphoma, leiomyoma are some of the less common types of colon cancers. The treatment depends on the type of cancer.

At what stage is the cancer?

Accurate staging of the cancer is based on histopathology and will be possible only after surgery. Colon cancer can be broadly classified into

Early cancer – cancer only within the colon with no spread of disease outside of it

Locally advanced – when the cancer appears large and or/ invading other surrounding organs, with enlarged lymph nodes

Metastatic – when the cancer has spread far from the colon, for e.g. to the liver, lungs, etc. These patients also usually have some fluid building up in the abdomen.

Now that I have been diagnosed to have colon cancer, how will I be treated?

Different types of treatment are available for patients with colon cancer. Three types of standard treatment are used:

• Surgery
• Chemotherapy
• Targeted Therapy

Surgery is the most common treatment for all stages of colon cancer. Some patients may be given chemotherapy therapy after surgery to kill any cancer cells that are left. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells either by killing the cells or stopping them from dividing. Targeted therapy uses drugs or substances to identify and attack specific cancer cells without harming normal cells.

Which kind of surgery is done for colon cancer?

The type of surgery depends on the location of the cancer and extent. There are curative and palliative colectomies.

Curative surgeries are done with an aim to remove the entire cancer with a margin of normal tissue around and all the lymph nodes involved (lymphadenectomy). These include:

- Right hemicolectomy refers to the resection of the ascending colon.

- Left hemicolectomy refers to the resection of the descending colon.

- Extended hemicolectomy is when a part of the transverse colon is also resected.

- Sigmoid colectomy refers to the resection of the sigmoid colon.

- Total colectomy refers to the resection of the entire colon.

- Subtotal colectomy refers to the resection of the part of the colon or a resection of the entire colon without complete resection of the rectum.

Palliative surgery is done for symptom control and not with intent for cure. This is because these surgeries are done in patients with advanced disease who have developed complications of the cancer (mentioned above). In an obstructing advanced cancer, only a bypass of the block (colostomy) may be possible. Sometimes, even if a patient is taken up for emergency surgery due to a complication of the cancer, no resection may be possible if the disease is very advanced and the colon will just have to be closed without any further surgical intervention.

In some patients with an obstruction who are not fit for surgery, endoscopic stenting of the tumour may be attempted.

Are there any alternatives besides surgery?

Till date, surgery is the only proven curative option for colon cancer.

How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anesthetist’s advice regarding continuation of medications if you are on any. A high protein diet is preferred to improve nutrition.

How major is the surgery? What are the possible complications?

Colectomies with lymphadenectomy and other colon surgeries are deemed as major surgeries with a risk of complications and a very small risk of death (<2>

The complications of Colectomies (removal of the colon and lymph nodes and joining back (anastomosis) the healthy bowel / intestine) include:

• Leak of anastomosis
• Bleeding from the anastomosis
• Bladder and ureteric injuries
• Injury to the duodenum
• Wound infections

For how long do I stay in the hospital?

In an uncomplicated case, hospital stay after surgery is 7-10 days. This may be longer when there are complications.

Will I need any further treatment after surgery?

The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymph nodes are positive and your general condition is good enough then you may be referred to the medical (GI) oncologist for consideration for chemotherapy.

What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival depends on the stage of the disease. The average 5-year survival for all stages after curative surgery for colorectal cancer is between 40-75?pending on the stage of the cancer. As of date there is no foolproof way of predicting which patients will have recurrence and which patient will not.

Are there any special precautions I need to take to prevent cancer from coming back?

No there are no such proven precautions.

How frequently should I follow up after surgery?

After completion of treatment you will be advised to follow-up once in 3-4 months in the first 2 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow up will be once a year. During each follow-up you will be asked to do certain blood tests, especially CEA. You may also be advised to get an ultrasound of the abdomen and colonoscopy done. Colonoscopy can show recurrence of polyps or cancer in the colon. In addition to checking for cancer recurrence, patients who have had colon cancer may have an increased risk of cancer of the prostate, breast and ovary. Therefore, follow-up examinations should include these areas.

What is Cervical Cancer?

Cervical cancer is one of the most common cancers amongst Indian females. It arises in the lower part or the “mouth” of the uterus. The cervix is the lower part of the uterus (womb) that connects uterus to the vagina (birth canal). It is highly preventable, can be diagnosed in early stages and is mostly curable.

Various strains of the human papillomavirus, also called HPV, play a role in causing most cervical cancers. HPV is a common infection that is passed through sexual contact. When exposed to HPV, the body's immune system typically prevents the virus from doing harm. However, in a small percentage of people, the virus survives for years. This contributes to the process that causes some cervical cells to become cancer cells. 

What are the Symptom of Cervical Cancer?

• Abnormal bleeding ( after sex / between periods / post-menopausal)
• Fowl smelling discharge from the vagina
• Pain during sexual intercourse
• Lower back pain or pelvic pain

What are the Stages of Cervical Cancer? 

• Early Disease:  Initial stage involving only cervix and small in size
• Localised Disease: Loco regionally advanced disease which is beyond cervix but limited to pelvic area.
• Metastatic disease: Disease has spread to other organs of body.

What are the Causes/Risk Factors of Cervical Cancer?

• Cervical cancer cases are caused by the sexually transmitted human papillomavirus (HPV).  The two types that most commonly cause cancer are HPV-16 and HPV-18
• Becoming sexually active at a young age (especially younger than 18 years old)
• Having many sexual partners or having one partner who has many sexual partners.
• Having many children. Young age at first full-term pregnancy
• Long-term use of oral contraceptives
• Low Economic status
• Smoking
• Having a weakened immune system

Screening and diagnosis of Cervical Cancer? 

Pap test is used to detect precancerous stages and is routinely done in normal females, usually annually. Treatment of precancerous lesions of the cervix can prevent cervical cancer.

A small biopsy sample is taken from the cervix if a Pap test shows abnormal cells, and is examined to look for cancer cells.

A positive biopsy result invariably confirms cancer and requires further imaging for staging such as USG, CT or MRI scan and chest X-ray. A complete staging is essential for deciding the best treatment.

What are the treatment options available for cervical cancer? 

1. Surgery: Involves removal of the cervix, uterus, and surrounding tissues. Surgery is generally recommended in early stages of cervical cancer.

2. Radiation Treatment: uses high-energy X-rays and gamma rays to kill the cancer cells. The required dose of radiation is delivered by two modalities usually one after the other, External radiation (EBRT) and internal brachytherapy (BT). During external RT, patient is positioned at the linear accelerator machine in the same way every day, and the radiation field is exposed to the radiation beam for a few minutes once per day, five days per week for five to six weeks. This is done as an outpatient procedure, and the patient can usually continue with normal daily activities during treatment. In this treatment Radiation along with concurrent chemotherapy is given. Locally advanced cases are mostly treated with chemo radiation.

3. Internal radiation (BT) is delivered through a device that is temporarily placed in the vagina and uterus. The patient is usually admitted for preparation for the procedure overnight and the treatment is given the next day under spinal anesthesia. Patient is discharged in the afternoon and the same process is repeated every week for 2 to 3 weeks.

4. Chemotherapy: weekly concurrent chemotherapy is given along with Radiation treatment in locally advanced cases as a part chemo radiation treatment. In metastatic cases generally triweekly chemotherapy is given.

Follow-up: 

After the advised treatment is completed, the patient is called for periodic follow-up for testing, examination and scanning every 3 to 6 months to look for any signs of the disease coming back.

How can cervical cancer prevented?

1. Primary prevention: Vaccination against HPV virus

2. Secondary prevention: Screening – Visual examination by aceic acid (VIA) Pap smear (every 3 years) , HPV DNA Pap (every 5years) , pelvic examination & Treatment of pre-cancerous  lesions 

What are Head and Neck Cancers?

Head and neck cancer is a term used to denote cancer that develops in the mouth, throat, neck, nose, sinuses, salivary glands, thyroid or other areas of the head and neck. Most of these cancers are squamous cell carcinomas, or cancers that begin in the lining of the mouth, nose and throat. 85% of head and neck cancers are linked to tobacco use, and 75 % are associated with a combination of tobacco and alcohol use.

What are precancers?

The chronic effect of carcinogens cause changes in the lining of the mouth. Features like white patches (leukoplakia), red patches (erythroleukoplakia), tightening of the mucosa (oral sub mucous fibrosis) or lace-like patches (oral lichen planus) are called pre-cancers or pre-malignant conditions, and indicate that the lining has started on its path to becoming cancerous. They can sometimes be halted by stopping the addictions.

What causes Head and Neck Cancers? (Risk factors)

1. Tobacco in any form, whether smoked (cigarettes, bidi, cigar, pipe etc.) or smokeless (gutkha, pudiya, gulmanjan, soorti, paan masala etc.) is the strongest risk factor. The habit of stuffing paan in the mouth while working long hours, is a unique risk factor mostly found in the Indian subcontinent.

2. Alcohol acts as an independent risk factor, and also potentiates the effect of tobacco by making its carcinogens more soluble, which can then be easily absorbed by the lining of the oral cavity and oropharynx. Therefore, alcohol and tobacco together are synergistic, not additive, ie 1+1=11, not 2.

How to suspect Head and Neck Cancers?

What are the treatment modalities?

There are many treatment modalities available which are tailored to the patient’s site, type and extent of cancer. The general fitness of the patient plays a role in his/her ability to tolerate the treatment. The treatments mainly used are:

Surgery

• Tumor removal, also called curative or primary surgery: Surgery is used to remove the tumor and some of the nearby healthy tissues. The tissue around the tumor is called the margin. Tumor removal may be the primary treatment in some types of cancer and may be used as the sole treatment, or in conjunction with other modalities, such as chemotherapy or radiation therapy.
• Salvage surgery- Patients whose disease recur after treatment with chemotherapy and/or radiation therapy are treated with salvage surgery. There is an extremely small window of opportunity for such patients, and they must be evaluated promptly.
• Diagnostic Procedures:  A biopsy may be used to diagnose certain cancers. During a surgical biopsy, the surgeon makes an incision into the skin to remove some or all of the suspicious tissue. This is sent to the pathologist to examine the tissue and diagnose the type of tumor, which dictates further treatment.

Radiation Therapy - Radiation therapy is the use of high-energy x-rays or other particles to destroy or shrink cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time, and maybe used either as the sole modality or in conjunction with surgery, chemotherapy or immunotherapy.

Due to chemotherapy and radiation therapy: 

Common side-effects of chemotherapy include - Mouth ulcers, nausea, vomiting, weakness, loss of hair, diarrhea, fever, loss of appetite, electrolyte imbalance etc.

Radiation therapy causes dryness of mouth, difficulty in chewing, difficulty in swallowing, dental caries (saliva is protective) and altered taste sensation, but these are minimized nowadays due to sophisticated radiation techniques. If the patient needs these modalities, he/she will be referred to the concerned specialist, who will explain the implications in greater details.

General Workup Needed For Diagnosis / Staging & Treatment Plan

All patients with suspected carcinoma of head and neck should be evaluated and should record the following:

A. History

B. Clinical Examination Performance

C. Nutrition status assessment

D. Histological diagnosis – FNAC/Biopsy/ Slide review

E. Imaging for extent of disease and assessment of operability

F. Clinical staging and

G. Documentation of the subsite(s) involvement

H. Investigations

• EUA / Endoscopy for mapping of disease
• USG for N0 neck in select case
• PET - CT whenever indicated

• X-Ray Chest CT Scan / MRI for extent of disease

Treatment decisions for all patients is made in a multidisciplinary joint clinic with the goal for maximizing survival and preservation of form and function.

In our day-to-day lives, we use a variety of materials and utensils in our kitchen, which are not natural and can strongly cause damage to our health. Let’s know some of the commonly used materials in our kitchen that are carcinogenic or cancer-causing.

PLASTICS

Plastics have become so common in our daily routine life that we hardly consider living without use of plastics in one or the other way. Well, this whole battle against the use of plastics started in 2009 when a viral email claimed that celebrity, Sheryl Crowe, developed breast cancer after leaving her bottle of water in the car. The email was falsely attributed to Johns Hopkins University and claimed that plastic bottles and food containers contain chemicals called dioxins, Phthalates and Bisphenol A, which are a group of chemicals used to soften plastic in food packaging and a wide range of other industrial and consumer products that can leach into food and drink, causing reproductive and developmental problems, liver damage and cancer, which led to a revolution among many to have a plastic free zone, kitchen, home or rather country.

What can you do?

a. Do not use plastic wraps or containers, which are not labelled microwave safe or rather use glass or ceramic containers

b. Do not use plastic containers not meant for food storage like cosmetic containers or chemical containers

c. Do not use store hot foods or hot water in containers not meant for it (e.g. Plastic containers for ice-cream or yogurt etc.)

d. Avoid using plastic containers having No. 7 written underneath ( No. 7 likely to contain BPA )

e. Wherever possible try to use glass, ceramic or stainless steel containers for hot foods and liquids.

TEFLON COATED PANS (NON-STICK COOKWARE)

PFOA (Perflourooctanoic Acid) which is used in preparation of Teflon coated pans is the culprit in causing various cancer (Testicular, Ovarian and Kidney). Although, it is burned off during the process and is not present in significant amounts in the final products it stays in the environment and blood for longer time periods. Higher levels can be found in community residents where local water supplies is contaminated by PFOA (Industrial wastes) and among people exposed to PFOA in the workplace. PFOA can be released by overheated nonstick pans and also by pans, which have lost its coating or is breached.

What can you do?

a. Try to use cast iron pans wherever possible.

b. Do not use nonstick pans if the coating is cracked or has come out.

c. Try not to overheat the pan and not to use sharp objects while working on it or cleaning.

ALUMINUM UTENSILS AND ALUMINUM FOILS

On cooking food (mainly acidic) in Aluminum utensils gets leached out and is absorbed into blood through gut mucosa causing harmful effects like Alzheimer’s disease, testicular and liver carcinomas.

What can you do?

a. Try to avoid Aluminum utensils instead use stainless steel or cast iron utensils

b. Use Parchment Paper instead of aluminum foil

c. Avoid tetra pack products or sauces sold in refill pouches or tube, canned food products instead use ones stored in glass bottles

d. Avoid using cosmetic products ( Antiperspirants, sun screen and toothpaste ) containing aluminum

e. Antacids and vaccines also contain aluminum.

f. Avoid drinking water which is being treated with ALUM

g. Various Baby foods and Infant formulas contain significant amount of aluminum and should be avoided instead make home based purees for weaning babies

REFINED OIL

In the process of making refined oil various chemicals are used (Hexane, bleach etc.), which are harmful to our body. In order to get a desirable consistency, often these vegetable oils undergo hydrogenation, which in turn leads to formation of Trans fats. These trans fats contributes to disorders such as that of the liver, diabetes, obesity, gastrointestinal disease and even cancer mainly breast cancer and colon cancers.

What can you do?

a. Try to use cold pressed oils and natural seed oils viz. ground nut oil, Extra virgin Olive oil, Coconut Oil, Mustard oil

b. Use butter from raw milk grass fed cows and the second choice, which is more accessible to most of us, is organic, which is from milk of grass fed cows with NO rBGH injected into them.

c. Try to avoid re-heating left over oils again and again

d. It is better to buy oil from a local store that specializes in oils.

MILK AND MILK PRODUCTS

In order to get more milk, cows and buffaloes are being injected with hormones, which, in turn, get secreted in their milk causing infertility, thyroid diseases and endocrinal diseases and should be avoided instead drink milk from grass-fed cows and dairy products which are organic.

Not everything is bad or cancer causing.

CANCER-FIGHTING FOODS

There are as such no cancer fighting foods rather there are foods which contain certain vitamin, minerals and compounds, which reduce the risk of cancer.

a. Fruits: Apple as the saying goes ( An apple a day keeps the doctor away ) contains Polyphenols and berries ( Blueberry, Strawberry etc.) containing Vitamin C, Minerals and dietary fibers help in reducing the risk of cancer

b. Cruciferous Vegetables like Broccoli, Cauliflower and Kale contain Vitamin C, Manganese and Sulforaphane which reduces the risk of Colon Cancer and Breast Cancer

c. Carrots with its rich content on anti-oxidants and beta carotene are fighters against cancer

d. Walnuts with pedunculagin in them gets metabolized to Urolithins and thereby reduced cancer risk

e. Legumes with dietary fiber content and vitamins and minerals reduces the risk of cancer

Balco Medical Centre recommends that everyone should live a healthy lifestyle and keep an eye on their diet and also watch out for the carcinogenic items in their kitchen and eliminate it, or at least, reduce its usage.