Q. What is cancer?

Cancer is a group of many related diseases that begin in cells, the body’s basic building blocks. To understand cancer, it is helpful to know what happens when normal cells become cancerous.

The body is made up of many types of cells. Normally, cells grow and divide to produce more cells as they are needed to keep the body healthy. Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. The extra cells form a mass of tissue called a growth or tumor. Not all tumors are cancerous; tumors can be benign or malignant.

Benign tumors are not cancer. They can often be removed and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Most important, benign tumors are rarely a threat to life.

Malignant tumors are cancer. Cells in malignant tumors are abnormal and divide without control or order. Cancer cells invade and destroy the tissue around them. Cancer cells can also break away from a malignant tumor and enter the bloodstream or lymphatic system and spread to parts of body away from the main tumor.

Q. What are the causes (risk factors) of cancer?

The basic mechanism of development of cancer is damage to genes. Any agent which can lead to gene damage is a potential cause of cancer. Among the common mechanisms, chemicals are one of the important causes. These chemicals may be from Tobacco or chemicals present in food, air, water, etc. Chemicals which have the potential to cause cancer are called carcinogens. Besides chemicals, radiation is another important cause of cancer. Radiation can arise from cosmic rays (rays from space), nuclear power plants, other radioactive sources, x-ray machines, radioactive ores, etc. Ultraviolet radiation from the sun can also cause some cancers, especially of skin.

A number of agents have been implicated in causing cancer. A large proportion of cancers are caused by living habits and environmental carcinogens:

• Tobacco – Causes cancer of the mouth, throat (pharynx), voice box (larynx), food pipe (esophagus), lung, pancreas, kidney, urinary bladder, and uterine cervix. At least 90% of lung cancer deaths are due to smoking.
• Alcohol – Increases the risk of cancers of mouth, pharynx, larynx and esophagus by increasing the permeability of the mucosa to various carcinogens especially tobacco.
• Ionizing radiation – Well established as an etiologic factor in the development of leukemia.
• Environmental exposure – Asbestos exposure can cause cancers of the lung, pleura and abdominal peritoneum. Excessive exposure to solar ultraviolet radiation dramatically increases the risk for skin cancers.
• Viruses and bacteria – Chronic carrier state of Hepatitis B virus increases significantly the risk of developing liver cancer. Viruses of the HPV & HSV family cause carcinoma of womb's mouth (cervix) and carcinoma of the oral cavity, the commonest cancer types seen in India. Helicobacter pylori is associated with increased risk of developing stomach cancer.
• Chemical agents – A number of cancers are related to increasing use of potentially carcinogenic chemicals in various aspects of life. These chemicals get to our body through air, water, food, etc. Air pollution caused by various sources can increase the risk of cancer. Carcinogenic chemicals in air can come from automobiles and industries and affect the lung. Exposure to certain chemical agents like benzene increases substantially the chances of developing cancer esp. bladder cancer.
• Dietary habits – Obesity and high intake of fat, animal protein (particularly red meat), salt-cured foods, and nitrate/nitrite additives in the diet does seem to increase the risk of development of cancer.

Q. What are the types of cancer?

Cancer is not one disease but a group of diseases. Cancers arising from different organs have different symptoms and different behaviour. Some of the cancer are very mild and can be controlled easily by treatment while some are very aggressive and do not respond to treatment. There are others which have an intermediate behavior. Two broad groups of cancers can be considered: cancers of blood forming system which in common parlance are also called "blood cancers". These include leukemias, lymphomas, myelomas, etc. Cancers of other systems or organs are also commonly called "solid cancers".

Q. How does cancer develop?

The functioning of all parts of the human body at all levels is governed and controlled by the genes. The genes can be thought of as a large and elegant software or information store which controls the development of human body and its normal functioning. The genes are responsible for cell multiplication, cell growth and cell death. All cancers are caused by some abnormality in the genes. Abnormalities in the genes or mutations arise because of different agents, which can cause damage to the genes such as chemicals, radiations, viruses, etc.

There are many different types of genes in the human body amongst them four broad types of genes contribute to occurrence of cancer by being abnormal. They are oncogenes, tumor suppressor genes, DNA repair genes, and genes related to "cell death mechanisms". A lot of research is going on to find out the complete genetic basis of cancer and this is likely to lead to new treatment options in future.

Q. Does cancer always cause pain?

Having cancer does not always mean having pain. Whether a patient has pain may depend on the type of cancer, the extent of the disease, and the patient’s tolerance for pain. Most pain occurs when the cancer grows and presses against bones, organs, or nerves. Pain may also be a side effect of treatment. However, pain can generally be relieved or reduced with prescription medicines or over-the-counter drugs recommended by the doctor. Other ways to reduce pain, such as relaxation exercises, may also be useful. Pain should not be accepted as an unavoidable part of having cancer. It is important for patients to talk about pain so steps can be taken to help relieve it. The fear of addiction or “losing control” should not stop patients from taking pain medication. Patients, who take medications for cancer pain, as prescribed by their doctor, rarely become addicted to them. In addition, changing the dose or type of medication can usually help if the patient has troublesome side effects.

Q. How to prevent cancer?

Although there is no guaranteed way to prevent cancer, people can reduce their risk (chance) of developing cancer by:

• Tobacco should not be used in any form whether smoking or smokeless
• Alcohol in moderation, say social drinking, one-two small 30 ml pegs of whisky, five days a week, is permissible. However drinking along with smoking is very unsafe as it sharply increases the risk of cancer.
• Avoid direct exposure to noon sun; use hat, full sleeve clothing, sun screen lotions and avoid noon sun bathing.
• A well-rounded diet, low in saturated fats and high in fresh fruits, vegetables, whole grains and fiber starting as early in life as possible does have impact on reducing the incidence of cancer.
• Proper sexual hygiene and oral hygiene should be achieved along with regular examinations.
• Regular exercise helps to reduce the risk of cancer esp. colon cancer

Although many risk factors can be avoided, some, such as inherited conditions, are unavoidable. Still, it is helpful to be aware of them. It is also important to keep in mind that not everyone with a particular risk factor for cancer actually gets the disease; in fact, most do not. People who have an increased likelihood of developing cancer can help protect themselves by avoiding the risk factors whenever possible and by getting regular checkups so that, if cancer develops, it is likely to be found and treated early. Treatment is often more effective when cancer is detected early. Screening exams, such as sigmoidoscopy or the fecal occult blood test, mammography, and the Pap test, can detect precancerous conditions (which can be treated before they turn into cancer) and early-stage cancer.

Q. How do I know about my risk of developing cancer?

A large proportion of cancers are life-style related. The chances of developing cancer depends upon choice of foods, smoking habits, drinking habits, personal hygiene standards and exposure to certain agents at workplace environment. (One should visit for medical counseling to a cancer specialist and identify whether one belongs to high risk group of people likely to suffer from cancer and get adequate investigations

Q. Why is cancer in India almost always detected in late stages?

Majority of patients are free of pain and other symptoms in the early stages. This asymptomatic stage leads to a delay in seeking medical attention and allows disease progression unchecked. There is also a reluctance to entertain and accept this diagnosis even when there are obvious pointers in this direction. As a result, most people are detected with advanced stages of the disease.

Q. How can cancer be detected at early stages?

Cancer can be detected in the early stages by screening and by seeking prompt medical attention for any worrying symptoms. Screening refers to examination and investigation of persons without any symptoms or signs suggestive of cancer with a view to detect cases of cancer before they cause symptoms. It is expected that by this approach cancers can be detected at a very early stage and thus lead to a much higher chance of cure.

• Screening has been found to be effective in early detection of cancer of the breast and uterine cervix, the two commonest cancers in women.
• Screening has also been found to be effective in prostate cancer, a common cancer of elderly males and. cancer of the large intestine (colon or rectal cancer).
• Screening for breast cancer is by breast self examination, annual clinical examination by a specialist and mammography (x-ray of the breasts done using special x-ray machines) starting at an appropriate age.
• Screening for cancer of the uterine cervix involves examination by a specialist and a test called the pap test which is a very simple test without any discomfort.
• Screening for prostate cancer involves examination by the specialist, a blood test for prostate specific antigen, and TRUS (transrectal ultrasound of the prostate).
• Screening for cancer of the large intestine involves examination of stool samples for present of blood (occult blood testing) and examination by a specialist.
   

Q. How does early diagnosis change the outcome?

Detecting cancer at the earliest, especially at pre-cancer stage, is very likely to yield best chances of lifetime cure, with much shorter treatment time, much less cost and much less toxicity and side effects from the treatment.

Q. What are cancer warning signals?

• Lump or swelling – A swelling or lump is a symptom of cancers of superficial body parts such as skin, breast, muscles, bones, etc. For breast cancer, which is the commonest cancer of women all over the world, a lump in the breast is the symptom in more than 90% of cases.
• A sore that doesn't heal – A wound, ulcer or sore caused by cancer does not heal on its own or with dressings. Ulcers in the mouth and in the back passage are especially worrying.
• Recent change in a wart / mole – The features of this are a change in size, itching, bleeding, ulceration, etc.
• Unusual bleeding or discharge – Cancer of deeper parts of the body can lead to bleeding or discharge. Cancers of the uterine cervix in women is a very common cancer in India. It causes dirty vaginal discharge and bleeding. Bleeding may be spontaneous or after intercourse. Similarly bleeding with urine and stools can be a sign of cancers of the urinary tract (kidneys, ureter or bladder) and intestines (large intestines, small intestines). Cancers of the lung often manifests with coughing of blood.
• Changes in bladder or bowel habits – Difficulty in passing urine, poor stream, etc can be because of cancers of the prostate. Similarly, constipation with or without episodes of diarrhea, passage of mucus with stools, etc can be a symptom of intestinal cancer.
• Nagging cough or hoarseness – Nagging, persistent cough is common feature of cancers of the lung and larynx. Change in voice is a common feature of cancer of the larynx and it can also occur due to lung cancer.
• Difficulty in swallowing or dyspepsia – Difficulty in swallowing is a common feature of cancer of the esophagus (food pipe) which is a common cancer in India. It starts with difficulty in eating solid food and progresses until it is difficult to swallow liquids or even saliva. Loss of appetite, heaviness after meals, nausea and vomiting are common features of cancer of the stomach.

Presence of these signs should prompt the patients to seek medical attention. It is important to realize that no symptoms or signs of cancer are exclusive. Similar symptoms can be and are often caused by non-cancerous diseases. However, whenever a possibility of cancer exists, the specialists should be consulted to exclude the diagnosis of cancer.

Q. How is cancer treated?

Basically, three main approaches to treatment of cancer are used: surgery, radiation, and, drugs. Correspondingly, three main types of cancer specialists are there for treating cancer: surgical oncologists, radiation oncologists, and medical oncologists.

The treatment of cancer is usually requires a multimodality approach as a large number of patients need to be treated with a combination of the approaches available. Thus, some patients may need only one modality of treatment, some need a combination of two modalities and some need to be treated with all three modalities to achieve the best results.
Cancer treatment can include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. The doctor may use one method or a combination of methods, depending on the type and location of the cancer, whether the disease has spread, the patient’s age and general health, and other factors. Because treatment for cancer can also damage healthy cells and tissues, it often causes side effects. Some patients may worry that the side effects of treatment are worse than the disease. However, patients and doctors generally discuss the treatment options, weighing the likely benefits of killing cancer cells and the risks of possible side effects. Doctors can suggest ways to reduce or eliminate problems that may occur during and after treatment.

Surgery is an operation to remove cancer. The side effects of surgery depend on many factors, including the size and location of the tumor, the type of operation, and the patient’s general health. Patients have some pain after surgery, but this pain can be controlled with medicine. It is also common for patients to feel tired or weak for a while after surgery.

Patients may worry that having a biopsy or other type of surgery for cancer will spread the disease. This is a very rare occurrence because surgeons take special precautions to prevent cancer from spreading during surgery.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells in a targeted area. Radiation can be given externally by a machine that aims radiation at the tumor area. It can also be given internally; needles, seeds, wires, or catheters containing a radioactive substance are placed directly in or near the tumor. Radiation treatments are painless. The side effects are usually temporary, and most can be treated or controlled. Patients are likely to feel very tired, especially in the later weeks of treatment. Radiation therapy may also cause a decrease in the number of white blood cells, which help protect the body against infection. With external radiation, it is also common to have temporary hair loss in the treated area and for the skin to become red, dry, tender, and itchy.

There is no risk of radiation exposure from coming in contact with a patient undergoing external radiation therapy. External radiation does not cause the body to become radioactive. With internal radiation (also called implant radiation), a patient may need to stay in the hospital, away from other people, while the radiation level is highest. Implants may be permanent or temporary. The amount of radiation in a permanent implant goes down to a safe level before the person leaves the hospital. With a temporary implant, there is no radioactivity left in the body after the implant is removed.

Chemotherapy is the use of drugs that kill cancer cells throughout the body. Healthy cells can also be harmed, especially those that divide quickly. The doctor may use one drug or a combination of drugs. The side effects of chemotherapy depend mainly on the drug(s) and the dose(s) the patient receives. Hair loss is a common side effect of chemotherapy; however, not all anticancer drugs cause loss of hair. Anticancer drugs may also cause temporary fatigue, poor appetite, nausea and vomiting, diarrhea, and mouth and lip sores. Drugs that prevent or reduce nausea and vomiting can help with some of these side effects. Normal cells usually recover when chemotherapy is over, so most side effects gradually go away after treatment ends.

Hormone therapy is used to treat certain cancers that depend on hormones for their growth. It works by keeping cancer cells from getting or using the hormones they need to grow. This treatment may include the use of drugs that stop the production of certain hormones or that change the way hormones work. Another type of hormone therapy is surgery to remove organs that make hormones. For example, the ovaries may be removed to treat breast cancer, or the testicles may be removed to treat prostate cancer.

Hormone therapy can cause a number of side effects. Patients may feel tired, or have fluid retention, weight gain, hot flashes, nausea and vomiting, changes in appetite, and, in some cases, blood clots. Hormone therapy may also cause bone loss in pre-menopausal women. Depending on the type of hormone therapy used, these side effects may be temporary, long lasting, or permanent.

Biological therapy uses the body’s immune system, directly or indirectly, to fight disease and to lessen some of the side effects of cancer treatment. Monoclonal antibodies, interferon, interleukin-2, and colony-stimulating factors are some types of biological therapy.

The side effects caused by biological therapy vary with the specific treatment. In general, these treatments tend to cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients also may bleed or bruise easily, get a skin rash, or have swelling. These problems can be severe, but they go away after the treatment stops.

Q. How can the family act once a family member is detected with cancer?

All issues of treatment strategies should be settled before starting any one therapy. Hasty start after consulting only one specialty, getting under investigated, leaving treatment midway, undergoing inappropriate surgery, lesser radiation sittings and low dose chemotherapy, can definitely compromise chances of permanent cure. Such hasty start may allow patient and attendants to feel falsely secure and may yield initial temporary cure.

Q. What patient and family should know from the cancer specialist?

Before the start of anti cancer treatment it is imperative to know the extent of cancer spread and its origin. One should also be aware of the benefits and risks of treatments and possible consequences if no treatment is taken. It should be clearly known that what will happen if no treatment is taken and how the given treatment choices will change the natural history of cancer. It should be clarified that how long the patient is going to live with or without treatment. Patient should know cost effectiveness of various treatment possibilities, planned breaks and follow up schedule.

Q. Which specialist should patient meet to get anti-cancer treatment?

There is no single doctor as wrongly conceived by general public as an "all round cancer specialist." No doctor is qualified enough to deal with all the three cancer specialties of cancer surgery, cancer radiation and cancer medicine. It is emphasized that all cancer care seekers should seek opinion of at least three cancer specialists (Tumor Board / Planning board) available. In India, there are specialists with DM in cancer medicine, MCH in cancer surgery and MD or DNB in radiation therapy. To get quick and correct decisions seek opinion of all the three cancer experts (Not one). A "Total Plan" clarifying the role of all three treatment specialties should be designed.

Q. How does a cancer grow and spread?

As mentioned above, the cells constituting a cancer have abnormal growth behavior. They keep on multiplying without control. The excess production of cells leads to formation of a swelling (also called a tumor). These cells also have an abnormal tendency to damage surrounding tissues through invasion. By invading local tissues, cancer can interfere with the function of the organs affected. Cancer cells also tend to spread to other parts of the body through two systems of circulation in the body. Blood vessels include a network of arteries, capillaries, and veins through which the blood circulates in the body. The lymphatic system carries lymph and white blood cells through lymphatic vessels (thin tubes) to all the tissues of the body. By moving through the bloodstream or lymphatic system, cancer can spread from the primary (original) cancer site to form new tumors in other organs. Through the lymphatic system, the cancer spreads to lymph nodes draining the cancer bearing organ and then to other parts of the body. Through the blood stream such as lung, liver, bones, brain, etc. These organs are commonly affected by spread of the cancer through bloodstream. Spread of cancer to other parts of the body is called metastasis.

Q. How is anti-cancer treatment delivered to the patients?

Patient may receive anti cancer treatment as outpatient department (OPD) care, i.e. without admission to the hospital, Inpatient care (admission in the hospital), Day care (day time short admission ) or home care i.e. at home under care of trained nursing staff.

Q. Can cancer spread to family members staying close to the patient?

It has been found that cancer in humans does not spread by sharing food, water, clothing, and casual sexual contact. No one can "get cancer" from another person. Thus the attendants need not fear and patient should not be socially isolated unless the patient has low blood counts which necessitate a protective environment.

Q. How is cancer distinguished from some other disease?

The presence of cancer can be guaranteed through tissue diagnosis. In human body there are about 200 tissue types and about 200 types of cancer. Either pricking cancer using fine needle or removal of sample for cancer cell type identification can achieve this. It should be noted that pricking or sampling cancer tissue does not cause cancer spread to distant organs if done by a specialist using all necessary techniques and care.

Q. What are the latest innovations in cancer treatment?

Cancer therapy whether cancer medicine, cancer surgery or radiation therapy, all are becoming more and more "targeted". Advances have brought in more patient friendly, less toxic and more effective "precision therapies".

Q. How are cancer medicines administered?

Cancer medicines can be given by mouth, or as injections in venous or arterial blood.

Q. What is the approximate cost of cancer medicine?

The usual cancer medicines cost between Rs. 1000 to Rs. 50,000 for a single course. However, newer medicines may cost Rs. 1-2 lakhs per course.

Q. Why is chemotherapy said to be painful?

One of the major problems in chemotherapy is the development of painful veins, once the chemotherapy is given through the veins of hands and forearms. Due to this there is problem of venous access especially in the later courses of treatment.

Q. How can we achieve painless administration of chemotherapy?

This problem can be bypassed by using central venous catheters, implanted venous ports, triple lumen central lines and peripherally inserted central catheters. Delivering chemotherapy in large central vein does not lead to painful veins.

Q. Will all cancer patients die of their disease?

Cancer is not necessarily fatal. In general, one out of three persons with cancer are cured permanently, another one third temporarily and last third are best managed for symptom control alone. No doctor is right in saying that there is nothing that can be done for a given patient.

Q. What should be done if the patient is suffering from terminal cancer?

The value of a person's life does not end when the death is near. "To live until you die", sums up the need of the family and the patient suffering from any terminal illness whether it is terminal cancer or end-stage heart, kidney, and lung failure. Anyone who says nothing can be done other than waiting for death, is always wrong.

Q. How best can the cancer physician benefit the patient?

The relationship of a cancer doctor does not stop at providing technical expertise alone. The doctor's role is that of a friend, philosopher and guide telling how to " add years to life" and "add life to years".

Q. Are clinical trials (research studies) available?

Yes. Clinical trials are an important treatment option for many cancer patients. Clinical trials are a critical step in the development of new methods of treatment. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease.