Thursday, December 13, 2012

Early Detection Of Cancer – Symptomatic Manifestations and Clinical Diagnosis

The Technical Session started with the introduction of Dr.G.K. Kallur, Director PET-CET, HCG Cancer Care Network, Bangalore by Dr V.S.Dixit, Retd.  Director General of Medical Services (Indian Navy)

Topic :- Early Detection Of Cancer – Symptomatic Manifestations and Clinical Diagnosis.

Dr. Kallur has twelve years of experience in the field on Nuclear Medicine who had established Nuclear Medicine Department at HCG. Serving  as the Director of Nuclear Medicine since Aug 1996m he has received advanced training in PET imaging, Nuclear Cardiology, and SPECT at Rush Presbyterian St. Luke’s Medical College and University, Illinois, USA.

His areas of interest are – Cardiovascular Imaging, Pulmonary Imaging, Hematologic Imaging, Endocrine system, Central Nervous system, Cerebrospinal fluid dynamics, Bone Imaging, Liver and spleen, Hepatobilliary, Gallium Imaging, Genitourinary Imaging and Therapeutic Nuclear Medicine. He played a significant role in establishing India’s first FDA compliant Cyclotron and PET Radiopharmaceutical unit.
Dr. Kallur began his presentation with applauding Dr. Ajai Kumar for covering up almost every topic in management of cancer.
Prevention and early detection of cancer was necessary for prevention of cancer deaths. The cases that come to him were already in very advanced staged said Dr. Kallur regretfully. It is difficult to draw a line and send the patients to hospice telling them there is nothing much a doctor can do for them.
Usually the patient who are going through cancer, first approach the local physicians who keep treating them for the symptoms. When the symptoms do not subside, they often keep changing doctors and medicine. Finally when they come to the realization that they are suffering from cancer, often it is too late for a cure.
 Cancer is preventable as 80 – 90 percent of cancer is caused due to bad habits and unhealthy lifestyle. Cancer may start on one site, but will go on involving and spreading to other parts of the body.
70-80% of cancer is detected quite late in our country, which makes it impossible to control the cancer growth. Early detection may not actually cure all cancers, but it can cure some cancers.  There are only a few types of cancer that can be prevented or diagnosed early enough to make treatment more successful. These include breast cancer in women, cervical cancer, lung cancer, melanoma, colorectal cancer, and prostate cancer.
Whether we like it or not, we want it or not, cancer affects each one of us directly or indirectly at some point in our lives. Preventing cancer is easier than you may think. Through simple lifestyle changes, we can reduce our risk of developing many types of cancer.   The points to keep in mind to prevent occurrence of cancer are as following:
1.       Avoid smoking, whether it is actual smoking or secondhand passive smoke. Though people know and keep hearing how bad cigarettes are for health, and increase the risk of lung cancer they do not stop smoking. Smoking is the most significant risk factors for cancers that we can reduce.  Smoking not only increases the risk of lung cancer but will also increase the risk for many other cancers including esophagus, larynx (voice box), mouth, throat, kidney, bladder, pancreas, stomach and cervix. About 70% of the lung cancer can be ascribed to smoking alone. Second-hand smoke (SHS), also known as environmental tobacco smoke, has been proven to cause lung cancer in non-smoking people. Smokeless tobacco which is consumed various causes oral, esophageal and pancreatic cancer. Consumption of tobacco in any other forms like Gutka or Zarda is one of the main reasons for increase in oral cancer cases. Dr. Kallur mentioned that betel nut contains carcinogens also and therefore chewing them should be avoided.

2.       Including fruits and vegetables which are rich in antioxidants in the daily diet will help repair the damaged cells. Green vegetables, orange and yellow fruits are foods that will help in prevention of cancer. Diet has been proven one of the risk factors for cancer though there has been no substantial proof of it. Some studies show that fruits and non-starchy vegetables may protect against cancers of the mouth, esophagus, and stomach. Fruits are known to protect against lung cancer. Diet which is high in fat and low in fiber, fruits and vegetables increases the risk of colorectal cancer. Watch the meats you eat, especially smoked or cured foods. Research suggests that a diet high in animal fat can lead to the development of certain cancers. A diet high in smoked foods, salted fish and meat, and pickled vegetables increases the risk factor for cancer.

3.       Air pollution and exposure to chemicals and other harmful substances in the environment is linked some types of cancer especially air pollution. Air pollution can be in form of second hand tobacco smoke, outdoor air pollution due to vehicles, industries and asbestos. Contamination of water due to arsenic has increased risk of skin, bladder and lung cancers. Also the pesticides used on food products are carcinogenic. Exposure to Sunlight is another risk factor for skin cancer. It is better to avoid direct exposure to sunlight, especially when the sun is high in the sky.

4.       Drinking excessive amounts of alcohol regularly increases your risk factor for cancer. People who drink and smoke get double dose of risk factor for cancer of oral cavity, pharynx, larynx and esophagus. Studies suggest that men who consume 2 alcoholic drinks per day and women who have 1 alcoholic drink per day significantly increase their risk factors for certain types of cancer. High intake of coffee and tea is also considered to increase the risk factors of cancer.

5.       Obesity is another risk factor for cancer. An overweight person has highly increased chances of developing cancer, therefore keeping weight under control and regular exercise is a good defense against cancer.  According to the report published by WHO, regular physical activity and the maintenance of a healthy body weight, along with a healthy diet, will considerably reduce risk of cancer.

6.       Development of industries has contributed to development of cancer to a great extent. Moreover some of the environment in industries creates occupational carcinogens that increase the risk factor of cancer of the lung, bladder, larynx and skin, leukemia and nasopharyngeal cancer. Mesothelioma (cancer of the outer lining of the lung or chest cavity) is to a large extent caused by work-related exposure to asbestos. Dumping chemical wastes of industries into water has not only increased the risks of cancer, but has led to many other health hazards as well. Workers who are exposed to Gasoline, diesel exhaust, arsenic, beryllium. vinyl chloride, nickel chromates, coal products, mustard gas, and chloromethyl ethers run the higher risk of developing cancer as all these products are carcinogens.

7.       The atom bomb that was dropped on Japan had given birth to various cancers, which is being suffered by generations even after decades of exposure. Exposure of the fetus to X-rays has led to lots of childhood cancers. It is best to avoid exposure of pregnant women to any kind of radiation.  According to the report published by WHO “Ionizing radiation is carcinogenic to humans. Knowledge on radiation risk has been mainly acquired from epidemiological studies of the Japanese A-bomb survivors as well as from studies of medical and occupational radiation exposure cohorts. Ionizing radiation can induce leukaemia and a number of solid tumours, with higher risks at young age at exposure. Residential exposure to radon gas from soil and building materials is estimated to cause between 3% and 14% of all lung cancers, making it the second cause of lung cancer after tobacco smoke. Radon levels in homes can be reduced by improving the ventilation and sealing floors and walls. Ionizing radiation is an essential diagnostic and therapeutic tool. To guarantee that benefits exceed potential radiation risks radiological medical procedures should be appropriately prescribed and properly performed, to reduce unnecessary radiation doses, particularly in children.
Ultraviolet (UV) radiation, and in particular solar radiation, is carcinogenic to humans, causing all major types of skin cancer, such as basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma. Globally in 2000, over 200 000 cases of melanoma were diagnosed and there were 65 000 melanoma-associated deaths. Avoiding excessive exposure, use of sunscreen and protective clothing are effective preventive measures. UV-emitting tanning devices are now also classified as carcinogenic to humans based on their association with skin and ocular melanoma cancers”.

8.     Certain viruses, notably human papillomavirus (HPV), cytomegalovirus (CMV), herpes simplex virus (HSV) and Epstein-Barr virus (EBV), are known to produce tumors in animals and cell transformation in vitro and they have been implicated in the pathogenesis of human cancers. All these viruses are also known to infect the esophagus. It is important to talk get immunized against infections to reduce not only the risk of cancer, but the infection itself. Hepatitis B can increase the risk of developing liver cancer. The hepatitis B vaccine which is routinely given to infants can also be administered to certain high-risk adults — such as adults who are sexually active but not in a mutually monogamous relationship, men who have sex with men, and health care or public safety workers who might be exposed to infected blood or body fluids. Human papillomavirus (HPV) is a sexually transmitted virus that can lead to cervical cancer HPV, in addition it may also increase the risk of cancer of the anus, penis, throat, vulva and vagina. The HPV vaccine is available to both men and women age 26 or younger who didn't have the vaccine as adolescents. Avoid risky behaviors that can lead to infections that, in turn, may increase the risk of cancer. Having sex with multiple partners without a condom increases the chances of contracting sexually transmitted infection — such as HIV or HPV. People who have HIV or AIDS have a higher risk of cancer of the anus, cervix, lung and immune system. Sharing needles should be avoided as it can lead to HIV, as well as hepatitis B and hepatitis C — which can increase the risk of liver cancer.
9.       Though not all, some of cancers can be genetic. Therefore it is important to know the family history of cancer which helps a person to take better measures towards prevention. It can also aid in genetic testing and counseling, to assist the individual in finding out if the presence of  a mutated gene that increases risk factor for cancer.
10.   Regular screening tests like the Pap smear and mammogram for are a woman, and a DRE (digital rectal exam) if for a man are very important for early detection of cancer.  The Pap and DRE can detect cellular changes before they become cancerous, and the mammogram may be able to detect breast cancer early. A rectal exam should be part of a woman's yearly gynecology exam.
Cancer in the early stages may not show up any symptoms, by the time the symptoms surface, the cancer will be in advanced stage. Cancer silently develops inside the body, only when it grows enough to press on nerves does it produce pain. At times cancer penetrates blood vessels and cause bleeding or may disrupt normal functions of organs.
In its early stages, cancer may have no symptoms, but eventually a malignant tumor will grow large enough to be detected. 
As it continues to grow, it may press on nerves and produce pain, penetrate blood vessels and cause bleeding, or interfere with the function of a body organ or system.
In early stages the doctors will be able to provide better treatment to patients, where as in advanced stages it may not be possible. Also the financial and psychological burden increases with the advancement of cancer.
Dr.Kallur also mentioned the 7 danger signs that helps and medical practitioner or person going through it to detect cancer.
 C - Change in bowel or bathroom routine and habits
A – A sore that does not heal with medications
U - Unusual bleeding or discharge
T - Thickening or lump in the breast, testicles, or elsewhere
I – Indigestion or difficulty swallowing
O – Obvious change in the size, color, shape, or thickness of a wart, mole, or mouth sore
N – Nagging cough or hoarseness
In addition to the above, other danger signals which warn about the presence of cancer are
·         Headaches
·         Sudden weight loss
·         Loss of appetite
·         Chronic pain that does not heal with time
·         Fatigue
·         Nausea and vomiting
·         Fever that persists
·         Repeated infections

Seizures, sleepiness, confusion, and behavioral changes can be symptoms of brain tumor; fortunately not all brain tumors are cancerous. Persistent hoarseness, soreness in the neck, difficulty in swallowing can be indications of esophagus cancer.
Usually in cases breast cancer there are no symptoms initially, but as the cancer progresses there could be appearance of a breast lump, Nipple discharge or redness Breast or pain in nipple, swelling of part of the breast or dimpling. Breast cancer stages range from early, curable breast cancer to metastatic breast cancer, with a variety of breast cancer treatments.
Ovarian cancer in early stages may not cause obvious symptoms but as the cancer grows, symptoms  like pressure or pain in the abdomen, pelvis, back, or legs, swollen or bloated abdomen, nausea, indigestion, gas, constipation, or diarrhea, fatigue may surface. In addition the patient may have shortness of breath, heavy periods, or bleeding after menopause and frequent urination. These symptoms are sure signs of cancer, and only an oncologist or efficient doctor will be able to assure absence of cancer.
Risk factors for ovarian cancer are family history of cancer, personal history of cancer, age over 55, women who have not been through pregnancy and menopausal hormone therapy.
The risk factors of breast cancer are age, family history, personal history, benign breast conditions, early menarche, late menopause,  dense breast tissue, race, exposure to radiations, having no children, not breast feeding, obesity, oral contraceptives, hormone therapy, alcohol consumption and lethargic lifestyle.
The symptoms of cervical cancer may include abnormal vaginal bleeding, discharge that may have mucus and be tinged with blood, significant change in menstrual cycle, bleeding or pain during sex.
As the cervical cancer progresses the symptoms may include anemia, pelvic, leg, or back pain, difficulty in urinating due to blockage of a kidney or ureter, leakage of urine or stool into the vagina due to abnormal opening (fistula) between the vagina and the bladder or rectum, and weight loss.
Risk factors for cervical cancer include, an ongoing infection of human papillomavirus (HPV), high-risk sexual behaviors, having an impaired immune system, exposure to diethylstilbestrol (DES) before birth smoking, and secondhand smoke.
Most of the cases of Anal cancer are mistaken for piles and fistula by people which prevents them from approaching oncologists until the cancer advances to untreatable stage.  Symptoms of Anal cancer include
·         Appearance of tumor near anal opening
·         Bleeding from the anus or rectum
·         Feeling of pain or pressure in the area around the anus
·         Itching or discharge from the anus
·         Change in routine of bowel movements
The risk factors for anal cancer is age over 50 years, infection of HPV, multiple sexual partners, receptive anal sex, inflammation around the anus, fistulas and sore that have been ignored and smoking cigarettes.
The tests can be conducted either by digital rectal examination (DRE), Anoscopy, Proctoscopy, Endo-anal or endorectal ultrasound and Biopsy to rule out cancer.
The barium exam was the only choice in earlier days, before the introduction of endoscopy. The barium swallow is still being used for some purposes, one of which is the study of strictures in the oesophagus as an adjunct to other techniques.
Colon cancer is related to high consumption of red meat among people. The type of cancer which was seen mostly in developed countries has been on rise in India in recent times.  Studies show that the increasing consumption of western style food with less fiber may be one key contributing factor for the change which is affecting mostly the young generation of India.
Presence of polyps as small, non-cancerous (benign) clumps of cells) in the colon can be cancerous in later stages. Changes in lifestyle like consumption of diet rich in fat and starch without fiber, not much physical activity, smoking, alcohol consumption,  family history of colon polyps and history of inflammatory bowel disease (two diseases Ulcerative Colitis & Crohn’s disease are known risk factors of colon cancer.
The signs and symptoms for colon cancer are also common in other diseases; therefore without proper tests the presence of cancer cannot be determined.
Persisting diarrhea, or change in consistency of stool, bleeding from rectum, blood in stools, pain and discomfort in abdomen, pain during bowel movement, feeling of fullness even after passing of stools and weight loss are the symptoms that may indicate colon cancer.
Thickening of the skin of breast or symptoms like redness, swelling, and warmth in the breast, often without a distinct lump in the breast could be indication of inflammatory breast cancer. The redness and warmth are caused by cancer cells blocking the lymph vessels in the skin. The skin of the breast may also appear pink, reddish purple, or bruised with ridges that are pitted, like the skin of an orange (called peau d’orange), which is caused by a buildup of fluid and edema (swelling) in the breast. Symptoms like heaviness, burning, aching, increase in breast size, tenderness, or a nipple that is inverted (facing inward) are also indication IBC.  
Dr. Kallur went to explain how to check for the changes in wart or mole, appearance of skin and watching out for other signs that may indicate cancer.
He also talked about the new treatment options like immunotherapy, gene therapy and other options that are being seriously considered now in management of cancer.
After the lunch session was dedicated to holistic medicines. The first topic covered was Ayurvedic Identification and Conceptual Analysis of Cancer by Dr. B.V. Kumaraswamy, Retd. Professor and Head : Indian Medicine Kidwai Memorial Institute of Oncology. 

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