Cancer is more feared and less understood. What still resonates in my ears are the words of my doctor: “Not early but treatable,” as he went through the report of stage three carcinoma in the left breast. The prognosis could have been much better had I acted on the warning signs and consulted an oncologist in time. I had felt a lump appear and disappear, redden and lighten and my resistance to fight simple ailments greatly reduced. I had thought it was menopause setting in, that it was just a temporary change, a tiredness due to multi-tasking, always in a state of denial.
Dr Tapaswini Pradhan Sharma is a Head and Neck onco surgeon, trained at the All India Institute of Medical Sciences, New Delhi. She is currently a Senior Consultant, Head and Neck Cancer, at one of the Capital’s Fortis Hospitals. She helps us better understand the surgical aspects of cancer treatment.
Why is surgery the basic of cancer treatment?
Surgery to a great extent remains as a mainstay of treatment for most solid cancers. Patient and tumour factors — the site and type of lesion and the stage of disease — have a significant bearing on the final decision-making for treatment of these cancers. Surgery guarantees complete removal of the local disease.
However, advanced tumours will require additional treatment with radiation, with or without the combination of chemotherapy, to prevent a relapse. Surgery is considered the primary course of cancer treatment when the disease is localised, and also when the biology of the tumour does not portend a distant spread. There are also cancers which are neither radio-sensitive nor chemo-sensitive; these tumours will again warrant surgical resection.
What is debulking?
The word ‘debulking surgery’ suggests removal of tumour volume as much as possible. If the surgical extermination is performed with curative intent, it is called cytoreductive surgery. These types of surgery are performed for certain brain tumours and ovarian cancers, to alleviate the patient’s symptoms, such as a decompression in the central nervous system and to make chemotherapy more efficacious in ovarian carcinomas. Sometimes debulking surgeries are performed as palliation, to relieve airway obstruction or to facilitate swallowing, thereby providing a better quality of survival time.
How is a surgical oncologist different from a surgeon?
Cancer surgeries should be performed by specialists trained in various specialities of surgical oncology. Cancers originating from different anatomical regions behave differently, and to understand the finer nuances, one needs dedicated training. Surgeries done by a general surgeon and a trained oncosurgeon may appear the same on the surface, but the eventual oncological outcome which shows up with time may be different to a great extent.
A lot of tests are prescribed before a surgery. Why?
A cancer patient is subjected to a large battery of investigations targeted at identifying different facts pertaining to the disease. Step one begins with a biopsy or FNAC for diagnosing cancer and its subtype. Following diagnosis, radiological investigations are asked for, to stage the disease (to understand its extent). Then a set of haematological investigations are performed to look into the functional status of the various organs to confirm fitness for the cancer treatment. Various tumour markers done during the course of examination also throw light on the tumour burden. At times, these investigations are able to pick up other coexisting diseases.
What are the next steps after a cancer surgery?
Following surgical resection (removing the cancerous part), a biopsy of the resected specimen is read in detail. This helps the clinician to assess the need for further adjuvant treatments and also offer the person a prognosis.
What do cancer stages and grades mean?
Most cancers have four stages. Patients often interpret stage four as the end of the journey, though it is not so. Stage three and stage four are considered advanced states, warranting intensification of therapy. Grading of cancer reflects their extent of differentiation. They can be high-grade cancers which behave aggressively and give a shorter survival period to patients, or they could be intermediate or low-grade; the latter have a better prognosis.
What are the general risks of a cancer surgery?
The general risks for cancer surgeries are the same as with other surgeries: haemorrhages, wound infection and others. Wound healing issues are exacerbated on account of poor nutrition, the side-effects of chemotherapy and radiation.
Head and neck cancer treatment often has issues pertaining to disfigurement, impairment of speech and swallowing. Lymphoedema (swelling) of the arm is common in breast cancer surgery. Abdominal surgeries can be fraught with anastomotic leaks (a leak where two sections are joined), while gynaecological/urological surgical treatments are associated with urinary complications or lymphorrhea (an abnormal flow of lymph).
How does a breast oncologist decide if it is a lumpectomy or a mastectomy that needs to be performed?
Breast cancers are treated either with a breast conservation surgery (lumpectomy with oncoplasty) or a modified radical mastectomy. The decision-making regarding the type of surgery is influenced by size and multi-focality (spread) of the tumour. Small breast tumours are amenable to conservation. Large tumours and multi-focal lesions on the other hand will warrant a modified radical surgery.
Who are the different kinds of specialist surgical oncologists?
Human anatomy is quite complex and intriguing. Cancers originating from the different parts are biologically very different and require a deep understanding to maximize the treatment results. Head and neck, breast, thoracic, gastrointestinal tract, urology, gynaecology and sarcoma to name a few.
What is head and neck cancer?
Head and neck cancers are malignant lesions originating from sites above the clavicular bone. Excluding the brain and the eye, the rest of the anatomical areas fall in this domain viz: oral cavity, oropharynx, nose, paranasal sinuses, larynx, hypopharynx, ear, thyroid and salivary gland.
What are the signs and symptoms of head and neck cancer?
Most patients with head and neck cancers present with signs and symptoms referable to the site of their lesion. Oral cancers, which account for 30-50% of these cancers, generally present with non-healing ulcer, abnormal growth, oral bleed, progressive trismus, abnormal loosening of dentition and a change in voice. While cancers of the voice box present with persisting hoarseness, cancers of the food passage present with progressive difficulty in swallowing. Nose and paranasal sinuses present with nasal obstruction, nasal bleed, may be accompanied with headache and visual impairment. Thyroid cancers and salivary gland cancers are mostly asymptomatic. Though the head and neck area is amenable to visual inspection, unfortunately only 12-13% of patients present in the early stage of the disease.
Surgery in most cases is a very complex affair. Who are the members of the surgical team and what are their roles?
The head and neck area is an anatomically complex region. It houses vital organs of speech, swallowing, chewing, smell and taste. Surgeries of this area are often cosmetically disfiguring with a loss of certain vital functions. All these can be restored to a great extent if the cancer surgeon integrates his/her work with a good onco-reconstructive surgeon. Therefore, the two teams, resection and the reconstruction are key members for head and neck cancer surgery. For all cancer surgeries, one needs a good intensivist to look into the immediate post-operative care.
Signing a consent form before surgery is compulsory. What should the family members keep in mind before signing the consent?
The consent form is an important official medico-legally document in the language of the patient. It is signed both by the members of the treating team and also the patient and attendants. This document clearly details the type of surgery which the patient will undergo and its associated complications.
It is important to remain healthy and cancer free. Do share best practices?
Cancer to a great extent has become a lifestyle disease. It is important to have an optimistic approach in life to boost the immune system which actually helps to defy this disease. It is important to abstain from tobacco and alcohol. At least half an hour of moderate to vigorous physical activity should be incorporated in the daily schedule. The importance of keeping the body weight under control should not be underestimated. A regular healthy dietary pattern comprising 400gms of vegetables and fruits of varied colors to be encouraged.
What are the various imaging techniques and how do they differ?
The choice of imaging is guided by the type, site and stage of the disease. Most cancers are imaged using Computed Tomography (CT), Magnetic Resonance Imaging (MRI) or Positron Emission Tomography CT (PET-CT). USG, nuclear scans, angiography are also used to complement. CT scans highlight bony tissues better, while MRI defines soft tissues with greater clarity. PET scans are used to detect the functional activity of the tissues.
In this three-part series, the author, a breast cancer survivor, speaks to oncologists about navigating the cancer care system
