Cancers are broadly classified into two types
- Hematological (blood cancers) e.g. lymphoma, leukemias
- Solid cancers e.g. oral cavity, breast, cervix, etc.
Establishing diagnosis requires a tissue diagnosis. Tissue diagnosis may be done by FNAC (aspiration of cells by fine needle) or biopsy (removal of bits of tissue by large bore needle from tumor or open biopsies). In modern oncology, without tissue diagnosis, it is unusual or inappropriate to start treatment based on clinical diagnosis alone. Tissue diagnosis is also important to perform molecular studies to select appropriate medical therapies.
The extent is assessed by one or more of the following imaging, which includes X-rays, Ultrasonography, CT scans, MRI, bone scans and PET scans. Also other procedures like endoscopy, colonoscopy, bronchoscopy, cystoscopy etc.
- In situ—abnormal cells are present but have not spread to nearby tissue.
- Localized—Cancer is limited to the place where it started, with no sign that it has spread.
- Advanced—Cancer has spread to nearby lymph nodes, tissues, or organs.
- Distant spread—Cancer has spread to distant parts of the body.
- The TNM system is the most widely used scientific cancer staging system, used by doctors.
Cancer is managed in a multidisciplinary team setting to improve outcome and decrease the morbidity of treatment. Members of multidisciplinary team include surgeons, radiation and medical oncologists/hematologists, radiologists, pathologists, general practitioners, nurses and allied health professionals and palliative care physicians. Cancer care coordinators also play an important role in the provision of coordinated care.
The three main modalities of treatment are surgery, chemotherapy or radiation. In select cases like early oral cavity cancers and ca cervix only a single modality of treatment like surgery or radiation will suffice. But in vast majority of cases a combination of more than one modality is required to give adequate cure.
Surgery is the most important integral part in management of all solid tumors (e.g. breast, oral cavity cancers etc.). In curative settings; it involves removal of primary cancer and regional lymph nodes. Surgery can be done upfront in early stages of cancer. In advanced cases, chemotherapy can be given to downstage the disease (neo adjuvant) and then taken for definitive surgery. In very locally advanced and metastatic patients where definitive treatment is not possible, palliative procedures to reduce the symptoms can be done.eg. intestinal bypass in obstructed bowel cancers, toilet mastectomies in fungating tumor of breast. In very select cases, where the disease has limited spread to liver or lung, surgical removal of these lesions is possible (metastatectomy). Also, reconstructive surgeries post major resection plays a very vital role in recent times, eg. whole breast reconstruction following removal of breast.
Medical therapies form an integral part in treatment of all solid cancers. Chemotherapy is given under various settings as described below.
- Curative - E.g. Leukaemia, lymphoma, germ cell tumors, choriocarcinoma, Ewing sarcoma/osteosarcoma, etc.
- Neo adjuvant - To reduce the disease burden (downstage) before definitive surgery, in combination with radiation or alone. E.g. Breast, esophagus, stomach, etc
- Adjuvant - To eliminate micro metastatic disease after surgery or radiotherapy. E.g. Breast, colon, ovarian, sarcoma, etc
- Concurrent with radiation therapy (as radio sensitizers) - E.g. Head and neck cancer, cervical cancer, etc.
- Palliative (to improve quality of life and prolong survival) - E.g. All Metastatic cancers
Radiation is given 2 ways: either high-energy rays are aimed from a machine (external radiation) or implants (radiation sources) are put into the body (placed) near the tumor. External radiation: Getting external radiation is painless, much like having an x-ray taken. It’s usually done in an outpatient setting, and the treatments take very little time. Treatment is most often given 5 days a week for 5 to 8 weeks, depending on the size, place, and type of cancer being treated. Radiation implants: In some cases, radiation may be given through implants placed (temporarily or permanently) inside the body. (Brachytherapy) Like chemotherapy, radiation therapy is also given under various settings.
- Curative - E.g. Head and neck, cervix, lung, prostate
- Adjuvant - To improve local control post surgery - E.g. head and neck, breast, brain
- Neo adjuvant - To reduce the disease burden (downstage) before definitive surgery, in combination with chemo therapy or alone. Eg. Esophagus, rectum, soft tissue sarcomas.
- Palliative - to improve symptoms Eg. Advanced local disease and metastatic cancers, to reduce pain in bone metastasis.
Aim of palliative care is to improve quality of life by controlling symptoms If a tumour can be shrunk by chemotherapy or radiotherapy, this would be an efficient option for controlling symptoms. In most cases, concurrent use of palliative care services and active anti-cancer therapy are necessary to maintain quality of life. In all these situations, it is important to identify and treat the cause of the symptoms.