World Cancer Day is observed on February 4 to raise awareness on cancer and to encourage its prevention, detection and treatment. Cancer is the second leading cause of death in the world. It can be defined in simple words as uncontrolled growth of cells. The second character of cancer cells is to survive on the normal cells of the body.
In general, the cells in a multi-cellular organism are programmed for collaboration but many diseases occur because these specialised cells failed to perform their assigned task. Cancer takes this malfunction one step further, not only is there a failure of cells to maintain their specialised function but the growth of cancer cells is unregulated.
The most significant risk factor for cancer is prolonged longevity. The other common risk factors for cancer include tobacco, alcohol consumption, sun and radiation exposure, use of certain chemicals and hormones etc. Lifestyle changes like poor diet, lack of physical activity and overweight, adulteration and pollution are also being blamed for rising incidence of cancer.
The definite diagnosis of any pathology can be made with tissue diagnosis (biopsy) only. It is more true in the case of cancer, because the treatment modalities for cancer are expensive and have more complication than other common diseases. The tissue diagnosis or biopsy not only defines the origin of the tumour but it also grades its invasiveness to the surrounding tissue.
The approach of the treatment depends upon all these above mentioned factors. The curability from a tumour is usually inversely proportional to the tumour margin. Hence sooner the diagnosis better the outcome. However, in our country where the health services are not at par with developed nations, the results are not always so.
Many patients consult the doctors with a delayed presentation because many times at early stage these tumours are painless and hence neglected by the patients as they don’t consider it worth consulting a doctor. I presume that this is one of the main factors that in our country people are going for cancer treatment at a delayed stage to the available health facilities.
Another feature of cancer is recurrence of tumour in addition to the distant spread. The cause of recurrence is usually residual tumours which are not visible to the surgeon during removal of the tumour however with the invention of newer modalities like bone scan, CT scan, MRI and PET scan the incidence of residual tumour has decreased as better pre-operative planning can be done.
In addition to the tumour burden and residual tumour, the other major determinant of treatment outcome is the physiological response of the patient to treatment. A patient who is already having poor health status is more likely to suffer, more than a healthy and a fully active patient.
The treatment modalities in the cancer patients are based mainly on whether the treatment is palliative or curative. Cancer treatment nowadays is multi disciplinary approach because cancer is such a disease which affects not only the involved site but it also spreads to nearby organ and to distant sites. The multidisciplinary approach includes surgery, chemotherapy and radiation therapy alone or in combination. This approach helps to eradicate or cure the cancer from the affected organ or prevents spread in distant organ.
However this combination of approach increases the chances of morbidity and sometimes mortality, because most cancer therapies are toxic. These patients are already fighting with the cancer and are in a systemically compromised state due to which they become unable to fight with the treatment induced toxicity.
The common side effects of chemo therapy and radiation therapy are nausea, vomiting, alopecia (loss of hairs) and low grade fever which can be managed with certain effective drugs. These patients usually have decreased body weight, anorexia and many psychosocial problems.
In addition to the above the patient needs empathy and supportive care not only by medical and paramedical staff but by the patients’ friends and family members. The common causes of death in these patients are infection and distant spread leading to circulatory, respiratory, hepatic and renal failure ultimately to multi-organ failure.
Being an orthopaedic surgeon now I will restrict myself to the treatment of orthopaedic cancer related to bone and soft tissue. The bone cancer constitute 1 per cent all body cancer, 3 per cent of bone cancer are seen in children. The common bone tumours in children are Osteosarcoma and Ewing’s sarcoma.
Osteosarcoma is a malignant bone tumour and it commonly involves bones around the knee. In order of frequency, proximal end of tibia and distal end of femur and proximal end of humerus are involved. Osteosarcoma is a fast growing tumour. A patient can succumb to death as it often spreads to the lungs. Ewing sarcoma mainly involves the pelvic bone and flat bones. Whenever Ewing sarcoma involves the long bone than it is usually involves the mid shaft of the bone.
These tumour usually give progressive pain and swelling around the involved bone. Pain in bones in tumours usually does not get relief from commonly prescribed pain killers and at a later stage pain does not get relieved even with narcotic drug. Sometime when the tumour becomes large, so do the intensity of the pain and the range of the motion of involved joint decreases and the patient become bedridden.
Bone tumours are usually treated with the combination of surgery, chemotherapy and radio therapy. Earlier these cancers were treated with the amputation of limb but nowadays with the advent of CT, MRI, bone scan and PET scan, the limb saving surgeries are being done frequently. MRI can tell the extent of the tumour. The bone scan and CT scan can show the distant spread of the tumour.
After knowing the extent of the tumour, surgical removal can be planned before surgery and better results can be achieved. The well planned meticulous surgery can remove the cancer completely but if it is left in local area because of any reason or the tumour has spread in the other part of the body then in such situation chemo therapy and radiation therapy can control the cancer cells. A surgeon should keep a margin of normal tissue around the tumour mass.
In conclusion, I would like to emphasise that like any other cancer treatment, the bone cancer treatment should be done by well-trained and experienced doctor in a well equipped hospital to save the limb and life of these patient.
(The author is an orthopaedic and joint replacement surgeon based in Dehradun)
Monday, 04 February 2019 | Gaurav Sanjay | in Guest Column