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The Diagnosis of Cancer

It is said that cancer creeps in slowly and therefore, it is often referred to as a 'silent killer'. There are more than 300 types of malignancies that may involve the many organs of the body. If the cancer occurs on the skin, like a non-healing ulcer or an inflamed mole, it is likely to draw attention and can be detected earlier because of its visibility. The important point is not to ignore any lumps in the head, neck, breast or elsewhere, or ulcers in the mouth or tongue that persist, even though they may not produce significant symptoms. It is the cancers that lie in deep organs that go undetected, and often spread beyond the confines of the organ of origin by the time of diagnosis. Cancers of the pancreas or the ovary are examples of problematic, deep-seated malignancies that are largely diagnosed late.

Cancer may be diagnosed as part of routine annual examinations done to exclude malignancy or other ailments like heart disease, hypertension or diabetes, or when a person shows specific symptoms and weight loss to a healthcare professional. Only seldom do patients with cancer show up as medical emergencies with bleeding or intestinal obstruction. A diagnosis of cancer at an early stage in the disease is associated with good prognosis and survival. A diagnosis of cancer does not have to spell doom. Early stage tumours have excellent prognosis. There is a huge variation in survival depending on the cancer type, organ involved, and the grade and stage of the disease. The method used to quantify the extent of disease, both locally and its spread in every patient, is designated as the 'stage of the

comfortable with. Someone who communicated well, was not in a hurry, did not bark orders and was explain each situation to her when it was required. It is our ability to communicate--not just the raw emotions of fear, happiness and anger, but our abilities to vocalize the details of our daily experiences--that sets us apart from the animal kingdom. It is strange, then, that communication skills are not actively emphasized during medical education. And many doctors, as a result, are poor communicators.

The only emphasis in medical education is on excellence in subject knowledge and in associated medical or surgical skills. The most important human aspect of medicine-the ability to communicate with the patient-gets little priority, under the assumption that this skill will develop naturally with practice. This clearly does not happen in many cases, patients need doctors to listen, and then list treatment options, weigh the pros and cons of each alternative with the patient, and help them make informed decisions. Getting greater clarity on the disease and treatment process benefits the patient emotionally and reduces suffering. It also improves participation and commitment to treatment, even though it may have little impact on the outcome.

I recall the case of Dr B who went to England to get his Fellowship of the Royal College of Surgeons (FRCS). He was outstanding as far as knowledge and skills were concerned, but he was rejected for the job and asked to return six months later after improving his communication skills. Upon achieving this, he was told the job was his for the asking. Automatic mastery in communication comes naturally only to a few doctors-most have only learnt by emulating their teachers and observing others. This acquired skill of good communication that builds trust does wonders for patient compliance in various diseases, including cancer. The doctor must place all necessary facts disease.

The grade of a tumour is the level of differentiation or how closely the tumour resembles normal tissue. High grade tumours have poorer resemblance to the normal tissue and therefore poorer prognosis. However, survival rates have more than doubled in the last forty years. Improved survival is attributable to medical science and the development of early detection tools as well as the advancement of treatment modalities.

During cancer screening, routine blood and urine tests measure specific markers associated with some common cancers; when detected, the abnormality points the doctor towards the organ involved. Further investigations such as imaging procedures-computed tomography (CT) scans, ultrasounds, magnetic resonance imaging (MRIs), radionuclide bone scans, positron emission tomography (PET) scans-and/or biopsies are used to confirm the diagnosis and determine the extent of disease.

Over the years, as cancer treatment modalities depend entirely on an accurate, specific and comprehensive diagnosis, the laboratory diagnosis of cancer has evolved into a fine art. This tissue diagnosis is a prerequisite before treatment is started. Several diagnostic approaches are available: For instance, exfoliative cytology, or the study of cells shed from a tumour, is used in the female genital system (PAP smear). Sputum, urine, body fluids and cerebro-spinal fluid (CSF) are used to make a diagnosis of cancer through the examination of cytology smears. Fine needle aspiration cytology for tumours is a minimally invasive procedure and can be done in the lymph nodes, breasts, salivary glands, thyroid, lung and liver. Incision biopsy or excision of the tumour gives a final histological report. Frozen section examination is used to make a quick diagnosis, as well as to assess the margin for residual tumour at the time of surgery. Sophisticated techniques like flow cytometry and molecular markers are used to further categorize some tumours.

Many tumour any additional tool against the cancer cells (see p. 35 in Targeted Therapy'). My advice to her at the time was to get a second opinion on the slides with a repeat of the markers-HER2 in particular-by fluorescence in-situ hybridization (FISH), a more sensitive test for the detection of HER2 than the routine test done in most laboratories. She got her slides reviewed, and the HER2 turned out to be positive when FISH was used, giving her an additional drug for specifically targeting her tumour cells.

In another instance, a seventy-five-year-old golfer developed slowly increasing symptoms pertaining to prostate enlargement-not uncommon at his age. His golfing partner suggested a visit to the urologist. The blood and urine examination did not reveal anything untoward. A prostate biopsy was diagnosed as high-grade cancer, and treatment was started. His condition progressively deteriorated and he slowly developed renal failure three months later. His nephew, a doctor, visited him and asked for a review of the biopsy slides. Two days later, the review returned a diagnosis of high-grade bladder cancer. This explained the almost normal levels of prostate-specific antigen (PSA), a substance produced by the prostate gland at the time of diagnosis and the complete lack of response to treatment directed against prostate cancer.

The renal failure was due to the obstruction caused in the ureter, i.e. the tube that drains the urine from the kidney to the urinary bladder. The original erroneous biopsy report was the result of the infiltration of the bladder tumour into the prostate. A second opinion before the start of treatment could have averted inappropriate therapy, waste of money and loss of time. The Importance of Communication

The Importance Of Commnunication

To my friend with the HER2 positive breast cancer, I had suggested that she interview a couple of oncologists before starting her treatment, and choose one that she was most gain the US Food and Drug Administration's (FDA) approval with information on these newer options. This data can and come into the market, the internet gets bombarded be accessed by the patient or caregiver, who then becomes aware of these newer drugs and their utility in their cancer Since the internet is ubiquitous in many Indian households. doctors should be open to the idea of discussing information gleaned from the internet if the patient brings it up. Caregivers frequently join care groups to keep abreast of the situation they find themselves in. A neighbour of ours was diagnosed with chronic lymphocytic leukaemia (CLL) at an age when this disease was still considered uncommon- she was only forty-one then. She had repeated relapses and many types of infections, including fungal pneumonia because of low immunity, but her spirit never failed her.

She even developed lymphoma of the ovary and lost an eye. Finally, a bone marrow transplant cured her. Years later, I asked how she managed to smile through everything. She said, 'I didn't want to know the negative outcomes of the disease-it was my husband who joined the CLL group online and had discussions with the other patients. I never corresponded, but he kept me updated with all the positive feedback.' She had found the perfect solution for herself for maintaining a positive frame of mind. She understood that knowledge about other people's complications would have impacted her negatively. Her husband on the other hand, the caregiver, was prepared for every eventuality.

markers are used to diagnose and follow up with the cancer patient. Once the diagnosis of cancer is established by pathology and/or radiology, it is then staged' to determine its extent Baseline blood investigations are done for further monitoring, Only after these are completed are the available treatment options--in accordance with standard protocols-offered to the patient. Then the treatment time frame is worked out and the treatment is started.

The type of treatment given depends on the pathology of the cancer cells and the stage. Out of surgery, chemotherapy and radiation therapy, any one, or a combination of two or more regimens can be selected. The importance of the accuracy of the pathology opinion cannot be overstated. It is based on this report after all that the treatment is given! It is an all-out war once the treatment starts. If the cancer is likened to a terrorist outfit, a multi-pronged attack against it is justifiable. To achieve this, the terrorist and its accomplices must be found and eliminated (surgeryl radiation therapy); their support system of funding and communication must also be destroyed, and sleeper cells must be identified and taken out (chemotherapy). Only then will there be complete annihilation of the cancer.

In some tumours, like breast and lung cancer, additional tests on the tumour tissue are necessary to determine the complete nature of the cancer before embarking on the treatment. Knowing all the potential targets in a tumour and selecting drugs to strike them all provides the greatest likelihood of effective elimination of all cancer cells, thereby achieving complete remission. A couple of years after my husband Arun's diagnosis, a friend faced a dilemma. She had undergone surgery after a diagnosis of breast cancer. It was oestrogen (ER) and progesterone (PR) receptor positive but the HER2 (human epithelial growth factor receptor 2) was equivocal. Being positive for HER2 would offer her an

related to the disease and its treatment before the patient before embarking on the medication. Doctors in India are highly qualified and skilled in their specialties, but they often fail in their ability to communicate. They sometimes reduce their interactions to making mere pronouncements. Some patients have education and access to the internet, and require expert information to gain understanding of their disease in order to make it easier to cope with the consequences. The less educated deserve no less of an explanation, and a discussion about the treatment options- especially for a disease like cancer, where the entire family is heavily invested in the patient's well-being and the financial implications are huge.

The Internet

The internet is a useful tool for finding information on cancer, and for connecting with other patients and caregivers. However, there is controversy among the medical fraternity regarding patients reading about their cancers online. Some feel that this should be avoided as patients may interpret the information erroneously, which could be counter-productive and add to their anxiety. This view may be particularly true about reading survival statistics, which are both confusing and frightening. Others feel that reading empowers the patient and the wealth of information is reassuring, allowing them better control over their decision-making. It is difficult to ascertain the reliability of the medical information, since the internet is not regulated. Good judgement while searching for internet data becomes critical. When in doubt, run the information past the healthcare team for clarity. There may be wisdom in getting the doctor's recommendation on websites for reliability. This would ensure accuracy and credibility of the source. Another issue that needs consideration is the fact that medical science is constantly evolving. As newer remedies