Tuesday, November 27, 2012

Dr. Ajai Kumar and Dr. Kumara Swamy views on Cancer Management


The next speaker was Dr.Kumara Swamy who spoke on behalf of Dr. Ajai Kumar who could not attend the seminar due to professional obligations.  Dr. Kumara Swamy has worked in the field of Radiation Oncology for over three decades. After serving in the HCG Curie Centre of Oncology as a consultant, heis currently, he is presently serving as a Consultant Radiation Oncologist at HCG where he joined in 2008. H e is expert in the field of External Radiation Therapy Procedures, and is a renowned person in Image Guided Radiation Therapy, Intensity Modulated Radiation Therapy, 3DCRT, Stereotactic Radio-surgery (Cyberknife), Stereotactic Radiation Therapy (SRT) and 2D Simple & Complex Palliative treatments. He is a specialist in operating Cyberknife which is the world’s first non-invasive surgery system, through which he has treated patients with various types of cancer for many years.
 He began his presentation with a few words about Dr. Ajai Kumar, the chairman of the HCG, the Health Care Global Enterprises Ltd, and Bangalore. Dr. Ajai Kumar was a professional who worked for the betterment of masses.  With a vision of providing high quality cancer care on a pan-India basis to all sections of the society, irrespective of their socio-economic status, he turned into an entrepreneur with the launch of 30-bed Bangalore Institute of Oncology (BIO), the only private cancer hospital in 1989.
Dr. Ajai Kumar is responsible for making the Linear Accelerator with 3D conformal therapy, IMRT, even in remote places of India.
His three mantras to fight cancer are
1.       Hit it early
2.       Hit it hard 
3.       The right treatment the first time
Here is the message shared by Dr. Ajai Kumar through his paper.
There has been transition as far as detecting cancers "Early" is concerned. CANCER is often related to end of life in our society, this has stemmed from the fact that we more than often detect cancer very late at an advanced stage in the past compared to the present day scenario. This is also the reason behind the stigma attached to cancer in the society, and the public perception to treat cancer patients as cancer victims. The reason why we are seeing a phenomenal increase in cancer can be attributed to improved cancer surveillance facilitated by technological advancements in diagnostic imaging and pathology apart from other attributable risk factors. With these cancer awareness and surveillance programs we have seen a trend for early detection of cancers in the population. The advent of technology today has seen improvements in diagnostic accuracy. Diagnostic accuracy such as using a digital mammogram / MRI instead of conventional mammograms or ultrasound has helped identify suspicious lesions more accurately than their historical counterparts. Secondly, image guided biopsies have helped reduce false negative rates. Usage of PET CT compared to conventional CT/ Ultrasound of abdomen, pelvis and bone scan to radiologically stage cancer has helped to accurately stage disease and facilitate the right treatment. Use of tumor markers such as Prostate Specific Antigen, CA 19-9, CEA, AFP etc and other immunohistochemical markers have helped us arrive at an accurate pathological diagnosis. Use of high end diagnostics coupled with increasing awareness and education about cancer, effective surveillance and screening program for high risk populations and community, outreach programs in rural areas with telemedicine to aid diagnosis and identification can play a key role in early diagnosis of this disease. Impetus has to be given to early diagnosis to facilitate good cure rates and reduce the cost of the treatment and debility due to disease and treatment. Secondly, cancer directed treatment involves a multimodal therapy that has been tested over the years for varied types of cancers. Surgery, radiotherapy and chemotherapy form the triad of cancer directed treatment. There have been several innovations in how these treatments have been imparted to cancer patients over the years. Surgery has been moving from a more radical approach towards organ preservation, shorter hospital stay, less post operative morbidity and minimally invasive and robotic surgeries. The intent of surgery can be to cure, manage or down stage cancer or symptom control. This is usually the primary treatment of choice in many early stage solid malignancies. Radiation is now more sophisticated with use of electrons, protons etc and high dose is possible to, cancer areas sparing the normal tissue using radio robotic surgeries. Earlier there used to be fewer numbers of chemotherapy drugs but today we have several options of giving 1st, 2nd and 3rd line drugs. Low dose metronomic chemotherapy is also showing some promising results and could be used to treat the cancer as a chronic disease. Other targeted therapies such as those that block angiogenesis, specific molecules that involve in growth or spread of tumor, drugs that interfere with cell growth signaling or tumor blood vessel development, promote the specific death of cancer cells, stimulate the immune system to destroy specific cancer cells, and deliver toxic drugs to cancer cells are also in the treatment cart for cancer patients. Differentials in tumor sensitivity to chemotherapy drugs and chronicity of the disease have ushered in concept of personalized cancer care. The treatment is tailored to suit the patient’s condition and cancer using all these multimodal approaches. It is imperative and important to understand that cancer needs to be treated the right way the first time, and there are no shortcuts available to circumvent the problem as of today. However, the focus of treatment should not be limited to tumor. Today we see a transition from cancer directed treatment that relies purely on tumor killing to treating the person who has cancer. Quality of life is given prime importance in treatment decision making. Quality of life is "not just relief from pain" but implies getting back to normal life or even better life than they had before they were diagnosed and treated for cancer. In holistic sense, it is a social, emotional, physical and spiritual wellbeing. Cancer directed treatment can impose severe hardships and distress inpatients leading them to feel helpless and distraught. Coping with helplessness and hopelessness, being depressed has shown to be related to poor survival and increased risk of relapse and progression compared to those who cope well with positive attitude and fighting spirit. It is in this context that mind body approaches such as prayer, yoga and meditation could be useful. Evidence has shown that other complementary approaches such as Yoga helps in improving mood states, quality of life, immune responses and sleeps and reduces symptoms of distress and fatigue in cancer patients. Evidence base for such therapies that improve quality of life of cancer patients should be encouraged and should be an add-on intervention to conventional treatment. Other complementary approaches such as Ayurveda need extensive research for testing its efficacy as a anti cancer therapy. However it should be noted that 60% of the anticancer drugs in the market today are discovered from folklore claims and one cannot be dismissive but only be cautious of its efficacy. Diet and lifestyle are not only an important risk for causation of cancer but also important as therapeutic modalities. A low fat and low calorie diet and physically active lifestyle has been shown to improve disease free and overall survival in breast cancer survivors who have completed cancer directed treatment. The need of the hour is to see a harmonious integration of all specialties of evidence based treatment to improve quality of life of cancer patients.
Dr. Kumara Swamy went on to explain why it was so important to treat the cancer properly the first time.  It is always very difficult to handle a recurrence, than fighting cancer the first time. It is also important to note the individuality of cancer before treating it. When cancer in detected in Stage 1, then the chances of cure are as high as 95%, which starts declining with the progress of cancer. He also stressed on the point that we should avoid using words like victims and survivors which strikes fear in the heart of the people. To remove the fear it was important to treat cancer as any other malady that affects human body.
He noted the importance of keeping pace with the advancement in treating cancer and understanding it thoroughly. The need for multidisciplinary surveillance program for the early detection of cancer is necessary as it goes a long way in saving lives. Prevention and timely screening are two most effective and pre-emptive defense against cancer. Prevention is better than cure- the old adage stands very well for the cancer.  By prevention of cancer we include
·         the methods involved in forestalling the activities that leads to cancer
·         early detection and treatment of pre-cancerous condition
·         catch the cancer at the treatable stage when the success is rate is high
·         Prevention of new of recurrence of second primary cancers in people who have survived cancer.
By following a proper screening process the cancer is detected when the number of malignant cells is small and highly acquiescent to treatment.
He had information to share about Digital Mammogram, which is fast replacing the standard mammogram in detection of breast cancer. The mammograms record images of the breast on film, whereas the digital mammograms store and analyze the information through the digital computer images. In a digital mammogram though X-rays are used, they are turned into electric signals and stored in a computer in the same way digital cameras take and store pictures.  Research has shown that the cancers that are missed on the film in standard mammogram are the type of cancer that proves to be fatal. Catching them by digital mammogram will save numerous lives.
Next he went on to explain the advantages of Targeted Biopsy which ruled out the incidences wrong diagnosis.  Through the guidance from digital imaging, the part of the most highly proliferative tumors can be excised for lab test.
Dr. Kumara Swamy was concerned how the hesitancy on the part of the people to spend on diagnosis will eventually incur them huge expenses in form of treatment. He also called upon the medical professionals to screen the high risk population to catch cancer in their early stages. Being assured of organ preservation and functional preservation would encourage more and more people to trust and go ahead with the diagnosis and treatment of cancer. For this, the medical professionals need to be more precise, which will lead to less mutation in the patient.  The team should consist of onco plastic surgeon to ensure the mutation caused by cancer or its treatment will be minimized.
During this session more information was imparted on the following:
·         Personalized medicines which were administered considering the individuality of the patient and type of cancer, and their effectiveness in battling cancer.
·         About the effects of principle stress hormones on cancer cells. Research has shown that stress related psycho-social factors are proportional to survival rate in cancer patients. Principal stress hormones Catecholamines and Glucocorticoids and their effects on tumor growth.
·         Stress regulation of Tumor Biology.
·         Process of treatment which should not only include relief from pain but also functional preservation of the patient
·         How the attitude of the person effects his/her recovery
·         Power of Yoga in treating cancer
·         Complementary medicines like Ayurveda which can be highly effective since most of chemicals that go into medicines are extracted from herbs and plants.
·         Removal of fear through proper assurance, support and counseling.
·         Considering cancer as any other chronicle  disease
·         Changing the expression of palliative care to managing disease. The terms like Terminal, palliative etc tends to take away the whatever remaining strands of hope are left in the patient
·         Propagation of philosophy to face the outcome of cancer.
·         Productive life even when facing the crisis.
·         Critical insurance to ease the financial burden of cancer.


The person who is affected by cancer should not stop on enjoying the little things of life. The need of the hour is to see a harmonious integration of medical facilities which will provide care to all. 

Monday, November 26, 2012

ROLE OF RADIOTHERAPY IN THE MANAGEMENT OF CANCER


The post tea session began at 12.40 p.m.
Dr. Dixit went up the dais and called upon Dr. Janaki M.G. Professor and HOD; Dept. of Radiation Oncology, M.S. Ramaiah Medical College and Teaching Hospital, Bangalore to present her paper on ‘ROLE OF RADIOTHERAPY IN THE MANAGEMENT OF CANCER’
Dr. Janaki mentioned she had joined the radiation department in 1989. In the past 23 years, she had seen tremendous improvement in the quality of life among the people going through the radiation therapy. The difference was caused by the intervention of computer technology in radiation department.
Medical science has used radiation therapy for curing cancer for more a century. When Wilhelm Rontgen discovered x-rays, immediately Emil Grubbe an American physician made use of it in treating cancer. But the major contribution to the radiation came from Marie Curie, with her discovery of radioactive elements.
In earlier times, radium was used directly on the patient’s skin through a radium surface applicator. The β-rays emitted were filtered by the applicator, but the back of the applicator left the person exposed to γ rays, thus creating occupational hazards of radium therapy with for the persons working with it.
Through the pictures, Dr. Janaki showed the earlier methods of treatments and risks involved in it. Today the radio oncologist concentrates on differentiating between the tumor and normal tissue, so that the damage to the healthy tissue could be minimized.
Doctors usually recommend radiation for patients after the surgery in most cases. It is usually a part of standard cancer treatment along with surgery and chemotherapy. Usually a radio oncologist studies the case history of patient before deciding the type of radiation required for the specific condition.
The 3 different types of radio therapy approaches are:
·         External radiation
·         Internal radiation
·         Systematic radiation
 In some cases more than one type of radiation therapy is given to the patient.

Concerns in Radio Therapy

During radiation therapy, there is loss of healthy tissue because radiation forms ions which are electrically charged particles in the cells through which it passes through. This process can kill cells or change genes in them preventing further growth. Unfortunately, radiation can distinguish between cancerous and non-cancerous cells. It destroys cells, irrespective of whether they are cancerous or not. In standard radiation treatment there is no way anyone can prevent damage to the normal tissue.
The major concern among the oncologists is to minimize the damage to healthy cells with accurately targeted radio therapy.  In this ventures the oncologist have been helped with advancement in technology which has given them devices like linear accelerator (LINAC) which is the device most commonly used for external beam radiation treatments for patients with cancer.
The linear accelerator which delivers high-energy x-rays to the tumor is used by oncologist to treat tumors in all parts of the body as these x-ray treatments can be designed in such a way that they destroy the cancer cells while sparing the surrounding normal tissue.
A careful plan of is made by the radiation oncologist in collaboration with other experts involved in the treatment like the surgeon, radiation dosimetrist and physician. Also he is guided before and during the therapy through 3D imaging, and conventional techniques with devices like Intensity-Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), Stereotactic Radiosurgery (SRS) and Stereotactic Body Radio Therapy (SBRT).
CyberKnife : Cyber Knife is a non-invasive robotic radio-surgery which can remove tumors and lesions that are un-operative under normal circumstances with standard technology procedure.  The oncologist is guided by the real time image guidance, to precisely target the tumor in any part of the body. The cyber-knife which is guided with technology similar to cruise missile, can deliver high dose of radiation with pinpoint accuracy.
A clinical picture of a case of cancer of Nasal Cavity which was effectively treated by cyber-knife was shown with the aid of pictures to show the astounding results.
Dr. Janaki also explained another form of radiation therapy known as Brachytherapy. It a process where the oncology surgeon implants a catheter into the cavity caused by the excision of the tumor. A part of the catheter protrudes outside the skin, which is treated by the medical professionals with antibacterial medicines to prevent infection in the area. 
For radiation therapy, the end of the catheter which is protruding outside the body is connected to a remote after-loader, which sends radiation directly to the site of cancer thus reducing injury to healthy tissue.
Paper Presented by Dr. Janaki
Radiation as soon as it was discovered was used to treat cancer way back in early twentieth century. Since then lot of development has taken place in the dosimetric aspects, delivery of radiation as well as supportive care. Hence Radiation not only gives better results but also is much safer resulting in less toxicity and improved quality of life. Initially the radiation delivery was based on clinician's knowledge alone or probably with addition of fluoroscopy/x rays. With the development of CT scans, the pre treatment planning as well as on table verification during treatment has helped to focus on the target area and at the same time normal tissues included are much less.
Improved technology and incorporation of computers into treatment process has enabled precise delivery and has become important as radiation is given in fractionation and over 6-7 weeks. It's important to give the same treatment everyday for all 33 — 35 sittings. Over the last decades, advances in medical and surgical oncology along with radiation have resulted in longer lifespan of the patients and hence more of localized recurrences are seen. It's a challenge to treat the patients as they already have a compromised immune system. It is here that the advances such as stereotactic radiation, image guided Brachytherapy play a role in precisely delivering the dose only to the tumor with almost nil doses to the surrounding normal tissues.
Overall Radiation offers optimal results not only in curative setting but also for postoperative, combined chemotherapy and for palliation.

Sunday, November 25, 2012

ROLE OF SURGICAL ONCOLOGY IN MANAGEMENT OF CANCER


The next presentation was by Dr. K. Sreekanth, M.S., M.Ch. (Surgical Oncology) Chief Surgical Oncologist Yashoda Cancer Institute, Hyderabad, who covered the topic of ROLE OF SURGICAL ONCOLOGY IN MANAGEMENT OF CANCER
According to Dr. Sreekanth, it is the fear and ignorance that leads to misconceptions about cancer. Cancer is a malady with dangerous capabilities but it can be overcome with proper treatment and attitude shown by the patient.
He rightly presented the example of Yuvaraj Singh who had battled cancer to make a comeback to play cricket once again. Attitude is everything in a person’s life. Positive attitude wins half the battle with cancer.
Cancer is associated with the lifestyles of people which are strongly related to economic development.  The incidences of cancer of breast, lung and colon are rising in developing countries.  The industrialized nations and urban areas register higher rate of cancer cases.
The surgeon plays an important role in prevention of cancer by identifying and removing lesions, polyps or tumors that could flare up into cancer cases when left untreated. The oncology surgeons have expertise in multidisciplinary management of major cancers that require surgery as a primary treatment along with radiation and chemotherapy. They are specially trained in removal of tumors with safe margins in cases of breast cancer, colorectal cancer, pancreatic cancer, liver cancer, melanoma and stomach cancer.
Surgical oncologist needs to have crucial cultural and interdisciplinary approach of cancer. He needs to have knowledge about biology, pathology, radiology, chemotherapy, and radiotherapy so that he will be capable of defining the limits of intervention keeping in mind the natural history of tumors.
Diagnosis of cancer
The signs and symptoms of cancer vary depending on the type, location and size of tumor. The methods used to diagnose cancer are
·         Fine needle aspiration biopsy (FNAB) in which the doctor uses a very thin needle attached to a syringe to withdraw small amount of tissue from the suspicious area to determine the presence of cancer cells
·         In Core Needle Biopsy of Tru Cut Biopsy a larger and hollow needle is used to withdraw tissues from abnormal suspicious area under local anesthesia.
·         Another form of Biopsy is Surgical (open) biopsy also known excision biopsy where the whole tumor is removed for further pathological study.
·         Blood tests
·         X-rays
·         CT, MRI, PET,  Mammogram and other types of screening
After diagnosis, if the tumor is found to be malignant then the surgeon will decide upon the surgical treatment of cancer. Surgically removing cancer tumor is the best chance of disease-free survival.
There are some important points to remember to make the surgery a success and increase the chances of recovery in the patient which every surgeon should keep in mind. Also proper preventive methods should be taken to prevent cancer metastasis because it proves to be more fatal then primary cancer.
Keeping sufficient margins is important, but it is also important to keep the mutation in check. In case of indispensable organs it is very important to maintain accurate margins so that there will be no loss of important tissue. Resection of breast cancer with good surgical margins is one of the primary aspects of breast conserving surgery.
Removing the margins clearly, can significantly reduce the chances of residual cancer recurring, especially with invasive form of cancer. So often recurrences occur due MRC (minimal residual cancer) or within a contiguous field of preneoplastic cells.
The goal of surgery in Metastatic breast cancer is prolongation of life and palliation in addition to prevent the symptoms from flaring up.  Metastatic cancers are generally assumed to be incurable and often the metastatic recurrence is more serious than the primary tumor proving life threatening in many cases.
Surgeries under oncology emergencies are often performed to stop internal bleeding, exsanguinating hemorrhage or any other potentially life-threatening conditions which may prove fatal without immediate intervention.
Oncology surgeries are also preformed for Percutaneous abscess drainage, especially in gynecologic cancer patients.
Palliative surgeries are those that are performed not for life saving, but to improve on quality of life, reduce the severity of suffering, relieve pain, or remove infection.
Colostomy or gastroenterostomy is for removing obstruction or stop the bleeding in urinary bladder, cordectomy to relieve pain, cystectomy to give relief from hemorrhage and amputation for removal of necrotic or infectious organ are some of the palliative surgeries performed.
Pain palliation is another challenging care needed for patients under severe pain, where the focus in on relieving and preventing the suffering of patients as much as possible.
Venous access catheters are quite helpful during the treatment of cancer, as it keeps the veins readily available for doctors and nurses to give medication andr nutrients or draw blood from the patient sparing the troublesome repeated pricks of needle.
Oncology surgery not involves removal of the cancerous tumors and tissues, but also helps in building the confidence of survivors through reconstructive and rehabilitative surgeries.
Dr. Sreekanth then shared with the delegates a video of Laparoscopic Esophagectomy explaining the details and complications involved in the surgery.
Surgical oncologist cannot perform as an individual, but needs the constant support of medical team to achieve success. The motto of this team is – Don’t just add years to life but add life to years.
Hope is one of the most important things in this struggle against cancer. He gave example of Lance Armstrong who battled cancer and defeated it, and moreover went on to win 7 Tour De France Championship. He has brought out his experience wonderfully in his autobiography, “It's not about the Bike: My Journey Back to Life.
Finally the session ended with the surgeon thanking his team, his supporters and his teachers.
Paper presented by Dr. Sreekanth
Surgery is the oldest form of cancer treatment and surgical oncologist is a specialist who focuses on the surgical treatment of variety of tumors with a goal to remove the cancer with clear margins. However, the contribution of surgical oncologist goes beyond what is done on the day of surgery itself and as a part of multidisciplinary team, he plays a major role in the holistic management of a cancer patient from curative to palliative care. Although technological developments will continue to play a role in cancer therapy, research in molecular biology and genetics will dictate the future of cancer treatment. The paper will deal with the basics of cancer diagnosis, early detection, screening, surgical management of cancers in community practice including advances.

Saturday, November 24, 2012

Incidence of Cancer: Prevntion and Early Detection for Effective Management

From National Seminar On Cancer Management

After the informative speech and presentations, it was time for questions to be raised by the delegates which were appropriately addressed by the speaker.
TECHINICAL SESSION
TOPIC
Incidence of Cancer: Prevntion and Early Detection for Effective Management
Speaker: Prof. Dr. Purvish Parikh MD, DNB, FICP, PhD, ECMO, CPI, MBA Medical Oncologist & Hematologist, Mumbai
The technical session began with the introduction of Dr. Parikh by Dr. S. Kumar. Dr Purvish M Parikh is a medical oncologist and hematologist who has broken a new ground in stem cell therapy in India. He is responsible for the first umbilical cord blood transplant as well as the first haploidentical transplant in our country. While working as a professor and head of medical oncology at Tata Memorial Hospital, Mumbai, he strived to lead several innovations in the field of medical oncology.
Adding to list of achievements Dr. Parikh has visiting fellowship at Harvard International, Boston and Oxford University, Oxford. He has also undergone extensive training at Royal Marsden Hospital, London; Memorial Sloan Kettering Cancer Center, NY and Johns Hopkins Hospital, Baltimore.
Finding time in his busy schedule Dr. Parikh contributes to various government undertakings while being a  Convener of Indian Cooperative Oncology Network, President of Indian Society of Medical and Pediatric Oncology, International Editor for JCO, USA, editor in chief of IJC and managing director of AmeriCares India Foundation.
Dr. Parikh began his presentation with statistics about the survival rate Childhood acute lymphoblastic leukemia (ALL) which is a type of cancer in which the bone marrow makes too many immature lymphocytes (a type of white blood cell). With great improvements shown in medical science, the diagnosis and treatment has a high success rate at present for ALL. The overall survival rate at present for children with ALL has reached 90%.
He also showed stats of where breast cancer has overtaken the cervical cancer as the most fatal cancer among the women of India. The reason as to why the incidence of cervical cancer came down is just simple fact that the awareness of personal hygiene created among the women. Awareness is the best tool to combat cancer. Watching out at the trends would give hints to prevent cancer. For e.g. The number of cases of cervical cancer is more in rural areas and cases of breast cancer are high in urban areas which is a clear indicator of different lifestyle increasing the risk of these cancers among women.
According to Dr. Parikh, 85% of cancers are caused due to unhealthy lifestyle followed by people. Making positive changes to lifestyle would lead to prevention of cancer thus saving the cost of treatment and human resources available in oncology treatment.
High Fat diet is increases the risks factor for cancers like breast cancer, colon cancer, pancreatic cancer and cancer of small intestine, where as high calorie diet is responsible for incidences of cancers like prostate cancer, type 2 diabetes and heart disease. The low fat, low calorie diet, consisting of fruits and vegetables will help a great deal in prevention of cancer.
Maintaining proper oral hygiene can bring down incidences of oral cancer. Also if the medical practitioners and dentists are able to identify conditions that may lead to cancer in future and take precautionary measure, that would contribute a great deal in prevention of oral cancer.
He called upon doctors to look out signs which could lead to cancer like
1.     Trismus - Limited jaw mobility due to tonic contraction of the muscles of mastication.
2.     Leukoplakia – Leukoplakia appear as patches on the tongue, in the mouth, or on the inside of the cheek, which mainly affects the mucus membranes of the mouth
3.     Erythroplakia - A fiery red patch that cannot be characterized either clinically or pathologically as any other definable lesion.51% of cases of Erythroplakia are known to end up an cancer.
Proper examination and treatment of such conditions are necessary to bring down the incidences of oral cancer along with avoiding consumption of tobacco, alcohol and other cancerogenic products. His emphasized the need for focusing on prevention of cancer rather than treating it, along with urging the government to bring about a revolution in cancer treatment along with other non-communicable diseases such as hypertension, diabetes and cardio vascular diseases through the 12th 5 year plan.
Dr. Parikh expressed his concern where majority of people affected by cancer were not being treated by oncologists as there was shortage of oncologists in our country. They only had access their family doctor or local physician. For this reason, efforts should be made to train the non-oncology medical practitioners in identifying signs of cancer. Proper examination of the patient with susceptible signs indicating cancer is a must.
With excellent power point presentation to back him up, Dr Parikh moved on address the most deadly cancer of the women in India where the lack of awareness about the basic self-examinations for breast cancer which is the only window to early diagnosis. The tests necessary for diagnosis of breast cancer are:
·         Self examination of Breast
·         Clinical examination of breast by a medical practitioner
·         FNAC
·         Core biopsy
·         X-ray
·         Mammography
·         MRI
·         Focused ultra sound
Once the diagnosis has been made, treatment should be delayed. Appropriate chemotherapy is necessary in tackling cancer well, along with other standard treatment like surgery and radiation.
Dr. Parikh also elaborated breast cancer that is HER2 postive; meaning it tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. The HER2 gene normally helps cell growth, division and self repair. Unfortunately when cancerous cells have the HER2 gene they divide, grow and repair themselves faster, making it a more aggressive disease which higher chances of recurrence. The solution is a highly targeted treatment by a specialist the first time.
Goals of the treatment and therapy in cancer should be
·         Curing the person of cancer and giving clearance as NED
·         Converting cancer into chronic disease
·         Prolong good quality of life for the survivors
·         Palliative care that focuses on relieving and preventing the suffering of patients.
·         Symptom control
He argued that unlike Hypertension and diabetes, cancer was curable; therefore more efforts should be invested in curing this malady.
The first chance is the best chance in winning the war with cancer. Dose intensity plays a great role in keeping cancer cells at bay. Counseling of the patients to let them know the doctors are working for them and will be there with them at every step is very important.
In case of being diagnosed it was important to approach the right doctor, meaning the oncology specialist for treatment. Also it is utmost important to complete the treatment as statistics have proven that incomplete is like getting no treatment at all.

Dr. Parikh divided the India into 3 different socio economic groups.
Rich
Middle class
Poor
15%
35%
50%

The 15% of the rich people could afford best treatment with advanced technology; therefore even with delayed diagnosis the rate of survival was good.
The early detection and proper treatment was not meant for the poor because these were the people who were not sure of where their next meal is going to come from. Even with high subsidy they could not afford the treatment. In some cases, if they did not work for a day, they would not be able to feed themselves and their families. In such cases prevention was only solution. Creating awareness about personal hygiene, oral hygiene, effects of tobacco, cigarettes etc would help in prevention of cancer to a great extent.
The main concern for the medical professionals should be the middle class people, who usually demanded quality treatment at affordable price.
Some NGO’s are trying to reach the goal of providing free medicines to curative cancers. CPAA and Cancer society of India have contributed a lot towards betterment of people affected by cancer.
The government of India has almost doubled the number of medical seats for doctors seeking specialization in the field of oncology since 2010, but the goal of having enough oncologists in India is nowhere in sight.
With dedication, sincerity and commitment the medical practitioners could help the patients win the battle with cancer. He stressed his point with a power point show depicting cancer as the tiger which was to get the zebra. The task of the doctors was to provide the zebra with a fast enough motorcycle to escape the clutches of the tiger.
After the seriousness of the debate, he ended this technical session by putting a smile on faces of everyone present.
More information regarding prevention, treatment and management of cancer is available on http://www.oncologyindia.org/

The Paper Presented By Dr. Parikh
Majority of 1 million new cancer patients seen each year in India are diagnosed in an advanced stage, leading to a significant number of deaths. In the light of the current limitations (financial, administrative and others) in the country, it can be expected that preparedness for the future is woefully inadequate. This also means that there is a need for radically different strategies to win the battle against cancer. Tobacco, which is involved in the development of more than a quarter of all cancers, is the single most important factor within our control. Common women's cancers are cervical and breast cancers. As tobacco habit starts in three fourth of instances at an early age, preventive strategies should commence in secondary schools. Periodic oral examination is the best surveillance mechanism. Preventive measures should also focus on common women's cancers like cervical and breast cancer. Proper screening goes a long way in early diagnosis of these conditions. Human Papilloma Virus (HPV) infection is clearly the commonest sexually transmitted disease globally and has a direct correlation with precancerous lesions as well as full blown cancers of the cervix, anus, vagina, vulva and penis. HPV infection therefore becomes the logical target for a preventive vaccine, especially since cervical cancer remains a major cause of morbidity and mortality in India as well as other developing countries. Based on the present vaccine protocol, it can be anticipated that approximately 70% of cervical cancers are preventable by vaccination. WHO has recommended, with certain caveats, that routine HPV vaccination of females be included in national immunization programs. Focussing on males, a total of 93 % of anal cancers are associated with HPV. In addition, approximately 25 to 33% of oropharyngeal cancers are probably also preventable by vaccination. Vaccination of boys will not only prevent cancers linked to HPV occurring in males, but also those due to the transmission of the virus by males to females. Only an extensive program to vaccinate both genders could lead to an eradication of the high-risk HPV types within a foreseeable period of time. Research on hepatitis B virus, and also on high-risk HPV has significantly changed the field of sexually transmitted disease and their consequences. They are applicable to both women and men. They prevent HPV-induced anogenital warts, precancerous lesions, cervical cancer oropharyngeal cancer and anorectal cancers.
As majority of Indian population is unable to access healthcare services due to several limitations, it is ideal to provide them healthcare at their doorsteps using Mobile Medical Units. Having the mobile medical units visit the same community on a regular basis ensures that there is continuity of care, especially for chronic diseases. This model is great because it allows the agency to pass on the benefit of health education, lifestyle modification and early detection in a manner that is trusted and respected by the communities. Combining it with the use of low cost effective screening tools it will have the dual benefit of saving lives by early detection when the cancer is in early stages and still curable as well as reducing the cost of treatment.
Cancer directed systemic therapy (of which Chemotherapy is a major component) has quickly become the mainstay of treatment in most instances. To provide the patients with optimal benefit, several factors need to be considered. Dose intensity impacts on RR as well as overall survival and is best optimized when cancer directed systemic therapy is administered by medical oncologists. Incidence of cancers is growing at an alarming pace. Significant resources are being earmarked by the government to tackle the menace of the big four non communicable diseases (NCDs) - of which cancer is a major component. Chance of cure and optimizing outcome is best when the treatment is given only by adequately trained, qualified and experienced experts.

Friday, November 23, 2012

MANAGING CANCER DURING TREATMENT AND BEYOND

From : National Seminar On Cancer Management


The paper MANAGING CANCER DURING TREATMENT AND BEYOND was presented by Dr. Niti Raizada Narang MD., DNB., DM., ECM, Consultant Medical Oncologist, Fortis Hospitals, Bangalore.
Dr Niti Narang has done Hematology & Stem Cell Transplant Fellowship, Hammersmith, London. She is a Gold Medalist, President of India Awardee.
Doctor Nidhi started her presentation with guidance in managing cancer during treatment and beyond.
Cancer is preventable, curable and treatable was her take on the dreaded disease.
She talked about the conventional cancer treatment which consisted of Surgery, Chemotherapy and radiation.
Treatment of cancer is a systematic therapy which should be followed step by step by both the doctor and patient to win the battle. In our country the diagnosis often happens late, so the treatment is starts late too. According to Dr. Niti “Over 70 per cent of the cases report for diagnostic and treatment services in advanced stages of the disease, resulting in poor survival and high mortality rates. The disease is associated with a lot of fear and stigma in the country. But what is worth emphasizing is that now with improving treatment modalities, ‘cancer survivorship’ has increased and so issues like fertility preservation are being brought to the forefront”
Breast cancer forms the most important part of cancer research and the treatment is done through systematic therapy, where the medical professionals are adding newer targeted agents or immunotherapy, chemo-therapy and hormonal therapy, every few months.
Breast cancer has overtaken cervical cancer as the most prevalent cancer among women in urban India. One out of 22 women develops breast cancer and this figure is increasing gradually in our country which could progress to match to match western figures of 1 in 8 women if proper preventive measures are not taken.
Some of the cancers are curable by chemotherapy while others are not. Some of the cancers are known to respond to chemotherapy and be cured even when in advanced stages like
·         Testicular cancer
·         Ovarian germ cell tumors
·         High grade non Hodgkin’s lymphoma (B cell and T cell)
·         Gestational choriocarcinoma
·         Hodgkin Lymphoma
The difference between chemo curable cancers and chemo resistant cancers is, chemo curable cancer started from cells that are designed to die whereas the chemo resistant cancer develops in a cell that is meant to live a long time and be resistant to death (e.g. a nerve cell).
Chemotherapy needs to be handled with care as is has many side effects of depending on the type of and the amount given. Anticipating and managing side effects can help to minimize them and provide the best possible experience for the person receiving chemotherapy. The side effects can be severe or mild depending on the patient and his/her reaction to chemotherapy.
Since anticancer drugs are made to kill growing cells, they also affect normal, fast-growing cells such as blood cells forming in the bone marrow and cells in the digestive tract, reproductive system, and hair follicles. Some anticancer drugs may affect cells of vital organs, such as the heart, kidney, bladder, lungs, and nervous system.
Dr. Niti also touched upon topics like the ‘objectives of systematic treatment, the settings of systematic treatment and the principles of therapy’. The main goals of a cancer diagnosis and treatment programme are to cure or considerably prolong the life of patients and to ensure the best possible quality of life to cancer survivors.
Dr. Niti also spoke extensively about the evolution of monoclonal antibody therapy for curing cancer. Today besides lymphoma, breast cancer is the disease for which monoclonal antibody therapy is best established. Trastuzumab is the first monoclonal antibody which has already entered routine clinical use in breast cancer treatment. A number of novel monoclonal antibodies are currently in development for breast cancer and other diseases.
The next topic was about organ conservation in cancer treatment. The conservation of organs is vital for better quality of life for the patient.
Today it is the era of Hematopoietic Stem Cell treatment for cancer. Effort is now focused on identifying cancer stem cells in various hematopoietic malignancies, and defining the cells of origin such that the stepwise accumulation of genetic/epigenetic events necessary for cancer stem cell development can be delineated. A detailed understanding of these processes could lead to development of therapeutics that more effectively treat hematopoietic malignancies and potentially other cancers.
From there on Dr. Niti touched the psycho-social part of cancer survival as to what the patient feels during diagnosis and treatment; how cancer affects the relationships, pattern of blaming and other such problems which are part of cancer.
The bonding between physician and patient adds new meaning to personalized medicine, especially in the treatment of cancer. Personalized medicine in the ‘war against cancer’ started with the era of biological markers. There were ‘magic bullets’ or targeted drugs to target important biological markers on tumor cells that came to be known as immunotherapy and helped reduce the side effects of conventional chemotherapy. Today, however, it is not just the medicine but also the physician-patient relationship that needs to be personalized. A physician has to figure out ‘what, how and when to convey’ and ‘How to help fight the patient fight his own mind’ to treat the patient effectively.
The personalized treatment and physician-patient partnership is of no less importance than the actual medicine, especially in case of cancer where an oncologist must play multiple roles of physician, psychologist, mentor and friend.
The oncologists realize that cancer is not just a battle against the disease but more importantly a patient’s war against guilt, fear, suffering and agony. They have to realize that breaking this news does not merely cause a magical disappearance of all happiness in a patient; it is more profound devastation in terms of unplanned events in a person’s life: thoughts of child’s marriage or education and fear of the unknown to name a few. The misery is compounded with repeated diagnostic investigations and frequent clinic or hospital visits for treatment.
The role of clinician is to be supportive of the patient by listening and caring for them. Truth telling is one of the tough times for the doctors. It is big decision when to say there is no hope.
At this juncture what is of utmost importance is the confidence imparted by the physician through ‘open communication’. With this the battle is redefined... Battle is about joys, sorrows, rewards and challenges of caring for people with cancer.
Oncology is not just a science but an art, a philosophy of human relations and understanding of human experience to a very serious ailment. There is no ‘blunting of emotions’. There is always a flood of emotion when you see a new patient and understand his/her circumstances. The important thing to remember is that this relationship is ‘forever’, from diagnosis to treatment to surviving cancer.
Cancer is not the end but the beginning of a different journey; advances in oncology have truly given life wherever possible. It starts with ‘never lose hope and faith’; then comes ‘telling the truth’. The relationship has to go beyond ‘the physician knows best’ attitude and enter a partnership in care, treatment planning and delivery.
In this era of overflow of information, it is very important to add meaning to the information that the patient or his/her family want to share and comprehend.
Coping with cancer should be done through support groups where patients who are in same boat can be there for each other with better understanding of their situations.
Paper presented by Dr. Niti
Oncology is not just a science but an art, a philosophy of human relations and understanding of human experience to a very serious ailment. For a doctor, there is no 'blunting of emotions over time. There is always a flood of emotion when you see a new patient and understand his/her circumstances. The important thing to remember is that the relationship between doctor and patient is 'forever ' - from diagnosis to treatment to surviving cancer. Cancer is not the end but the beginning of a different journey. Advances in oncology have truly given life wherever possible. Managing cancer starts with 'never lose hope and faith'; and then comes 'telling the truth'. The relationship has to go beyond 'the physician knows best' attitude and enter a partnership in care, treatment planning and treatment delivery. Therefore today in the 'Era of Personalized Medicine', it is not just the medicine but also the physician-patient relationship that needs to be personalized.

Wednesday, November 21, 2012

QUANTUM MAGNETIC RESONANCE THERAPY IN CANCER MANAGEMENT — AN OVERVIEW


The next presentation was by Dr. G.S. Nayar Founder Director Anytime Medicare Services Pvt. Ltd., Bangalore
QUANTUM MAGNETIC RESONANCE THERAPY IN CANCER MANAGEMENT — AN OVERVIEW
Introduction to Dr. Nayar :  Dr. Nayar served the Armed Forces Medical Service in the Indian Air Force for over three decades, in areas of Specialist aero-medical and family practice, teaching, research and clinical applications of technology. His expertise and experience as a Senior Advisor (Aviation Medicine) and Professor (Aerospace Medicine) at the Institute of Aerospace Medicine and Rajiv Gandhi University of Health Sciences Bangalore helped him to shape the Ojus concept. An enthusiastic advocate of technology, Dr. Nayar's zeal has manifested itself in the form of wide spread ICT and medical technology usage in most of the care programs in Ojus.
Dr. Nayar began his presentation with an overview introduction of OJUS.
Ojus Healthcare Private Limited is a Bengaluru-based care provider committed to delivering comprehensive, cost effective primary care to citizens from all walks of life. Established in 2001, Ojus currently owns and operates a chain of clinics in the states of Karnataka and Kerala, specialized in corporate, residential and school healthcare. Ojus services are used by major Information Technology companies located in Tech Parks such as Info Tech Park Bangalore, Bagmane Tech Park Bengaluru, Technopark Thiruvananthapuram, and Infopark Kochi to name a few. Residents of the Sobha Lakeview Apartment Complex and students of Deen's Academy, both at Bengaluru , are some of our other esteemed care recipients.
Ojus also provides specialized treatment using the Cytotron ®, a state-of-the-art tissue engineering technology and medical system, for treating Degenerative Arthritis and advanced Cancers.
Dr. Nayar continued his presentation with introduction to tissue engineering and Cytotron. Cytotron is a device developed for Tissue Regeneration, Degeneration and Repair for the purposes of treating several chronic or degenerative diseases such as Cancer & Arthritis. The treatment modality is non-invasive, painless and free from side effects. Cytotron has been a great breakthrough in tissue engineering.  He also elaborated on functioning of the Nucleoproteins with cell growth, molecular medicine and Nano medicine.  The goal of this field is to understand and re-direct natural processes for repair of damaged DNA, as well as to reengineer to provide a clinically applicable gene correction technology.
RFQMR (Rotational Field Quantum Nuclear Magnetic Resonance) is the technology and Science behind a process and CYTOTRON is a device that produces and delivers RFQMR.
CYTOTRON is a huge machine, which looks like a modern whole body MRI scanner but has a bigger bore. The bore has a gantry that carries about 864 guns (older versions have 288 guns). Each of the guns produces high instantaneous magnetic field and radio frequency, it also consist of a special near field antenna and parabolic reflectors to deliver these signals. These guns emit packets or Quantum of programmed signals in time and space that are focused to the target of interest using laser guides. These emitted string of packets, which contain the dosimetry required for a specific medical condition is delivered by the antenna. The beams are than rotated in 360 degrees around the target.

The patient is made to lie down on a traveling bed, the bed travels into the bore of the CYTORTON, the laser guides come on and the technician focuses the guns as per a pre-prepared template. The secondary dosimetry that is prepared by a trained Doctor is initiated from the control room, and the CYTOTRON starts its job. After completing the assigned dose of radiation, the device automatically stops. The patient is than removed out of the bore.
The functioning of Cytotron on cancer cells
Cancer cells are cells that have lost control, by overriding the rule of DNA they keep multiplying uncontrollably.  Every cell of our body has a DNA that controls the functioning of our body through the cells. With mutations in cells, the code is overrun and there is chaos as rules are not being followed by cells. Our immune system and drug therapies try to fix the problem with the mutate cells but do not succeed always, especially in cases of cancer.
In a way RFQMR uses specific dosimetry to retune cellular signaling programs and restore optimal cell functions. Normal cells restart following RFQMR exposure without a problem because their DNA is normal. However, the cancer cells with multiple defects in the DNA (i.e. mutations, chromosome alterations and viruses) prevent its retuning, which would cause tumor cells to stop growing or commit suicide.
Rotational Field Quantum Magnetic Resonance (RFQMR) technology utilized highly complex quantum electromagnetic beams in the sub-radio and near-radio frequency spectrum. The beams are precisely controlled and focused onto tissues to alter the proton spin inside and outside the cells therein generating streaming voltage potentials. This alters cell membrane potential and "Jams" the "Command and Control" of the target tissue cells stimulating cartilage growth.
The team that developed Cytotron after years of research at CARD was headed by Dr Rajah Vijay Kumar DSc.  Dr Kumar is a pioneering researcher and an opinion leader in the field of Biophysics and Radiobiology. Specialized in Medical Engineering, he has worked for more than fifteen years on regenerative tissue engineering and high speed biological data acquisition, modeling and simulation of the human cardiovascular system.
RFQMR technology utilizes a totally different approach compared to conventional cancer treatments. Instead of the very high frequency ionising radiation used in radiotherapy RFQMR uses radio or sub-radio frequency, low power, non-ionising, non thermal electromagnetic waves.
Dr. Nayar presented the delegates of the seminar with clinical profile of the patients who have undergone the treatment under this technology. With one patient whose toe had been severed, with the help of latest tissue engineering technology, the medical team had grown the toe back. Dermal replacement techniques can now restore original tissue to those who have lost it to trauma, disease, or other accidental causes.
A phase 1 clinical study has been held at the Institute of Aerospace Medicine in Bangalore India between 2004 and 2006 on more than 100 terminal cancer patients. All patients were undergone all possible conventional interventions such as chemo, radiotherapy or surgery prior to RFQMR and yet the disease cannot be controlled and they are supposed to die within a few days to few months due to cancer. Out of such patients:
·         There is a 90% symptomatic relief (such as ease of pain, stop using pain killers, no more weight loss etc)
·         In most of the patients the tumor progression is stopped or reversed
·         More than 60% survived more than 1 year
·         More than 35 % went back to normal lives and living disease free for 2 years
 According to Dr. Dr. Rajah V. Kumar, out of the treated Terminal Cancer patients, the one year survival rate was 52% (including patients who died of heart attacks kidney failure etc.,) while 92% of the patients had improved quality of life, for whatever period they lived. All their research outcomes are audited by International third party audit and not the mere analysis of the project investigators.
Dr. Nayar ended his presentation by explaining the applications of Cytotron in various treatments.
Conditions Treateable with Cytotron
Initially Clinical Studies were focused on Osteoarthritis and Cancer. As Tissue engineering can be applied to almost every part of the body and treats at the very basic level the potential applications will be:
http://www.cytotron.com/images/cytotron_clip_image001.jpgStimulation of Angiogenic Growth Factor and promoting Coronary and peripheral pro-angiogenesis 
http://www.cytotron.com/images/cytotron_clip_image001_0000.jpgOsteo-arthritis
http://www.cytotron.com/images/cytotron_clip_image001_0001.jpgRelieving pain, and disability due to trauma 
http://www.cytotron.com/images/cytotron_clip_image001_0002.jpgCarpal tunnel syndrome
http://www.cytotron.com/images/cytotron_clip_image001_0003.jpgOsteoporosis
http://www.cytotron.com/images/cytotron_clip_image001_0004.jpgPain management / Fibromyalgia 
http://www.cytotron.com/images/cytotron_clip_image001_0005.jpgMigraine
http://www.cytotron.com/images/cytotron_clip_image001_0006.jpgDiabetes, Diabetic neuropathy
http://www.cytotron.com/images/cytotron_clip_image001_0007.jpgProblem wounds healing
http://www.cytotron.com/images/cytotron_clip_image001_0008.jpgTinnitus
http://www.cytotron.com/images/cytotron_clip_image001_0009.jpgDrug resistant epilepsy


Dr. Nayar’s Paper
Quantum Magnetic Resonance Therapy (QMRT) using the Cytotron® is a recent and indigenous addition to the emerging technologies in the management of solid malignant tumors. The medical device can deliver highly complex quantum instantaneous nuclear magnetic resonance beams in the radio and sub-radio frequency range with a near field delivery using specialized antennae. Precise calculations are made by its computer, based on tissue proton density (PD) measurements obtained from specific axial PD sequences of MRI. The radio frequencies (RF) set up resonance in the protons of the hydrogen of water molecules in the tissues, which can alter the trans-membrane potential (TMP) of the tumor cells and their mitochondria to the specific requirements. In cancer cells the TMP is of the order of-20 to -30 mV instead of the normal - 70 to -90 mV seen in healthy cells. The normalized TMP results in the restoration of the normal communication channels for command and control of various cell functions. This arrests the uncontrolled process of cell division and multiplication seen in malignant cells and results in apoptosis. The process is mediated through gene expression of appropriate p53 and p73 groups of proteins synthesized by the mitochondria. The clinical trials using QMRT are giving increasing evidence in support of this hypothesis. There is an impressive record of increased cancer-free survival even in some very advanced cases of cancers, who otherwise could not have survived beyond a few days or weeks. This paper presents an overview of treatment, results, improvement in the quality of life in terminal cases, and the increasing international recognition for the device. The need for more multi-centric trials at our leading Cancer Centers is emphasized.