DNB (Gen. Surgery), DNB (Surgical Oncology),
Fellowship in Laparoscopy & Robotic Surgery,
Consultant Surgical Oncologist & Laparoscopic Surgeon

Introduction:

In last century, most common cause of death after road traffic accident was infectious diseases. Presently, non communicable diseases are increasingly taking toll over infectious diseases. Cardio-vascular diseases and cancer are at present the leading causes of death in developed countries, accounting for approximately 70-75% of total deaths. The prevalence of these diseases is showing an upward trend in most of developing countries like India and for several reasons this trend is likely to increase. With increasing care for cardiac patients and development of good quality setups in urban as well as rural areas (Cathlabs), mortality due to cardiac events has been reduced in last couple of decades. Life expectancy is increasing with all these measures. As we started wining battles against infectious diseases, cardiac problems newer enemies are standing in front of us and i.e. Cancer.

What is Cancer?

The word cancer came from Greek word: “karkinos” first used by Hippocrates (400 B.C.), which means crab. It is thought to reference with appearance of blood vessels on tumours resembling a crab’s claws reaching out. Another scientist Rudolf Virchow defined origin of cancer i.e. “omnis cellula e cellula”, meaning cells come from cells. All cells of cancer come from a single cell. “Cancer is a disease caused by the uncontrolled growth of a single cell”. Cancer Cell is a replica of our own normal cell behaving in an abnormal way.

Hallmarks of cancer are:
1. Self-sufficiency in growth signals (i.e. cancer cell do not require any stimulus for its multiplication)
2. Insensitivity to anti-growth signals (i.e. cancer cells do not respond to inhibitory signals of body)
3. Evading apoptosis (normal cell dies after its function is over i.e. apoptosis but cancer cells do not die)
4. Limitless reproductive potential
5. Sustained angiogenesis (to grow further cancer cells acquire their blood supply)
6. Tissue invasion and metastases (these cells starts invading adjacent tissues, vessels and lymphatic’s to go to distant organs leading to metastasis)
7. Genomic instability

Terminology in cancer biology:

• Neoplasia: new growth
• Hyperplasia: increased cell number
• Metaplasia: mature cell type replacement
• Dysplasia: altered epithelial cell size, shape and orientation. CIS most severe form
• Invasion: malignant cells penetrating through
• Angiogenesis: acquiring new the basement membrane blood supply
• Metastasis: spread of cancer cell from primary site to distant organs

Epidemiology of cancer in India:

International Agency for Research on Cancer official web site; GLOBOCAN estimates that about 14 million new cancer cases were diagnosed worldwide in 2012 and slightly more than 8 million cancer deaths occurred. One million of these new cases and nearly 7, 00,000 of the deaths occurred in India, it accounts for 17% of the global population. Age-adjusted incidence of cancer for India is 94 per 1, 00,000 people, only slightly more than half of the world average of 182 per 1, 00,000. In India, 25 – 30 lakhs estimated cancer cases are present at any point of time. Around 70 – 80% of cancer cases are detected at later stage when treatment is difficult. Over 70% of cancer deaths occurred between ages 30-69 years (200,000 men and 195,000 women).

Majority of cancer cases that occurs in India are due to preventable causes. In men, the most common cases of cancer are tobacco-related (42% of all cancers in men). For Indian women, cervical cancer is the most common cancer which is due to viral infection. According to a study, leading cancer in Indian men (age group 30-69) are oral (23%), stomach (13%) and lung (11%) while in women of same age group are cervical (17%), stomach (14%), breast (10%).

What we all can do to improve present scenario:

• First change mindset: accept that cancer is curable disease
• To know key symptoms of common cancers
• Proactive questioning in asymptomatic patients
• Opportunistic screening
• Good communication between primary care physician and oncologist

Many people feel that having cancer is a death sentence for them. There are many types of cancer today which can be successfully treated & cured. The quality of cancer care has increased enormously in recent years. Increasing numbers of people in the west are surviving cancer and leading a normal life. However, survival rates for many forms of cancer are worse in India than the rest of the world. Many people are dying of cancer whose lives could have been saved. Others are having much more extensive and unpleasant treatment than might have been the case. Reasons for not having better chances of survivals in India are:

• Many people don’t know enough about the key symptoms and signs of cancer.
• Many people are so worried about cancer that they delay going to the doctor for as long as possible.
• Thus, by the time it is diagnosed, cancer is often in very advanced stage.
• May need very extensive treatment
• May not be treatable at all
• Limitations of our Health System
• Lack of proper screening programs

Common cancers:

• Clinical presentation and their principle treatment:

Oral Cancer:

It constitutes 30% of all cancers in Indian men

Common Symptoms :
• Any ulcer or growth in oral cavity
• Loosening of the teeth or pain around the teeth or jaw
• Any persistent lump or swelling

Diagnosis: Biopsy from ulcer or mass is required for diagnosis. CT scan oral cavity and neck with CXR are need for staging.

Treatment: Surgery is the principle modality of treatment. If detected early no adjuvant therapy is needed. Also extent of surgery remains less with better functional and cosmetic outcomes. In advanced cases oncoplastic surgery is done to give better results. If advanced disease i.e. (T3, T4 or lymph node positive) adjuvant radiation or concurrent chemoradiation is required.

Lung Cancer

It is most common cancer worldwide and one of the commonest in India

Symptoms and signs:
• Chronic cough
• Blood in cough
• Change in the voice
• Chest pain
• Shortness of breath

Diagnosis: Is done by CT scan followed by biopsy of lesion. For staging PET-CT scan is ideal modality.

Treatment: in early stages is surgery but major present at advanced stages where chemotherapy and newer generation targeted therapies (like EGFR, ALK INHIBITORS) are recommended.

Stomach Cancer

Increasing incidence in India probably westernization food habits.

Common Symptoms:
• Recurrent indigestion
• Dyspepsia
• Recent onset weight loss

Diagnosis: Upper GI endoscopy and biopsy is done to diagnose gastric cancer. CT scan abdomen and pelvis, CXR are used to stage the disease.

Treatment: Surgery is the principle modality. Radical subtotal or total gastrectomy is done depending on site and extent of lesion. In locally, advanced disease neoadjuvant chemotherapy is used to downstage disease before surgery. In metastatic setting palliative chemotherapy improve symptoms and prolongs life.

Colorectal Cancers

Though less common in India because of change in food habit incidence is increasing.

Common Symptoms:
• Blood in stool
• Feeling of being bloated
• Change in bowel habits
• Constipation

Diagnosis: Colonoscopy and biopsy is required for tissue diagnosis while CT scan abdomen and pelvis is needed for staging.

Treatment: Surgery is curative as well as palliative in presence of obstruction, bleeding, perforation. In elective, setting depending on site colectomy is done (right hemicolectomy, left hemicolectomy, and sigmoid colectomy). (For rectal carcinoma neoadjuvant chemoradiation followed by surgery is standards of care. Very early lesions can be cured with surgery alone). In advanced stage, adjuvant chemotherapy is needed. All colorectal cancer surgeries can be performed laparoscopically. The advantages of laparoscopic surgery are no scar, early return of bowel function and deceasing the time for resumed to daily activities.

Key Message:

• Be aware of the early warning signs for cancer
• Encourage and help people to speak to their primary care physicians
• Encourage people to take part in cancer screening programmes
• Spread the good news - If caught early, many types of cancer can be cured.