Together we can conquer!

The awareness of cancer among the public is much better now, thanks to the various media. April is Oral cancer awareness month oral cancer includes cancer that affects the Head and Neck as well. So, it can as well be called Head and Neck Cancer awareness month!

Symptoms of Head and Neck cancer:

As mentioner earlier oral cancer refers to cancer that occurs from the base of the skull to the oral cavity in the upper part of the chest, pharynx, etc. And a number of symptoms related to mouth ulcers or sores that do not heal are listed below:

  • Swelling that persists for over 3 weeks
  • A lump or thickening of the skin or lining of the mouth
  • Pain when swallowing
  • Loose teeth with no apparent reason
  • Poorly fitting dentures
  • Jaw pain or stiffness
  • Sore throat
  • A sensation that something is stuck in the throat
  • Painful tongue
  • Hoarse voice

All these will be present as lymph nodes; lumps may also be present in the neck region.

 

Predisposing factors that cause Head & Neck Cancer:

  • Smokers who use of tobacco in any form such as cigarette, cigar, or pipes are six times more likely than non-smokers to develop oral cancers.
  • Smokeless tobaccousers who use dip, snuff, or chewing tobacco products are 50 times more likely to develop cancers of the cheek, gums and lining of the lips.
  • Drinkers who consume alcohol in excess are six times more likely to develop Oral cancer than non-drinkers.
  • Human Papillomavirus (HPV) and certain HPV strains are etiologic risk factors for Oropharyngeal cancer.
  • Bad oral hygiene
  • Life style

 

Prevalence in India

India has the highest number of Head and Neck cancer patients in the world, mainly due to the use of tobacco.

In India, while Head and neck cancer is the most common form among men, it is the second among women, the first being breast cancer. Head and Neck cancer in India accounts for 30% of all cancers.

Over 2 lakh people have Head and Neck cancer in India. Overall, a hundred in a million, or one or two in a thousand people have this cancer.

North India has more cases of cancer than South India. Assam has the highest incidence of oral cancer in India.

Occurrence of Cancer also depends on the socio economic status of the patient.  People belonging to the high socio economic class are more prone to Breast cancer, whereas those from lower economic class, are prone to Cervical cancer or oral cancer. Oral cancer is more among lower socio economic class  because lack of proper food leads to more usage of tobacco.

Usage of tobacco in any form, especially chewing it leads to oral cancer.

Head and Neck malignancies among most patients with stage I or II cancer can be successfully treated with either surgery or radiation therapy. Chemotherapy (chemo) may be given with radiation, especially to treat any cancer left after surgery. Both surgery and radiation work well in treating these cancers.

Surgery is the main course of treatment in oral cancer followed by radiation therapy.

Nowadays the main concept in surgery is “organ preservation”. In recent times removal of organs is done only as a last resort but not as the first option. Earlier the main treatment would be surgery.

But, now the treatment involves radiation therapy, especially for cancer in larynx, nasopharynx and oropharynx.

Survival rate after oral cancer surgery

An early detection and proper treatment increase the survival rate- at least  by 10 years, when detected in stage 1. The first two years of treatment are very important in oral cancer. If, after treatment, the patient does not continue his old habit the survival rate is better. Survival also depends on the site of cancer, stage, Histology and predisposing factors and associated factors.

Generally Predisposing factors among non-smoking, non-alcoholic men are of utmost importance and ensure a better survival rate. It is these factors that account for better survival rate among women, compared to men. Recent studies also prove that HPV positive patients have better survival rates.

Mode of Treatment for head & neck cancer:

Surgery, radiation therapy and chemotherapy are the usual methods to treat and manage Head & Neck Cancer. But, what is of major concern is that all the three have side effects. In surgery we remove an organ, the patient will show visible changes.

In radiation therapy, the patient will not show visible changes. In the current times with modern equipment, high energy x rays are used to treat patients. Intensity modulated radiation therapy is used nowadays.

The most common way to give radiation for these cancers is to carefully focus a beam of radiation from a machine outside the body. This is called external beam radiation therapy or EBRT. To reduce the risk of side effects, doctors carefully figure out the exact dose needed and aim the beam as accurately as they can to hit the tumor.

Before your treatment starts, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — takes longer.

Treatments are usually given 5 days a week for 6 to 7 weeks.

Radiation is commonly given using techniques that help doctors focus the radiation more precisely, such as such as three-dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT). These use the results of imaging tests, like MRI, and special computer programs to precisely map the cancer’s location. Radiation beams are then shaped and aimed at the tumor from several directions, in order to avoid or minimize the damage to normal nearby tissues, which is far better than older methods of giving external beam radiation.

In IMRT we do verification  every week. IGRT is the latest method of doing verification on a  daily basis. Every day the position of tumour is checked  and treated accordingly.

Another latest technology is Rapid Arc treatment, where Machine goes around the patient’s body and radiates in the shape of arc. Now we use Respiratory gated radiation therapy to counter the physiological changes.

At GKNM, we have all the latest technologies to treat any form of  cancer. The department of Radiation Oncology is equipped with state-of-the-art facilities like a dual energy   Linear Accelerator with Intensity Modulated Radiation Therapy. A  Linear Accelerator with Image Guided Radiation Therapy, Rapid Arc and RPM Gating which was procured to cater to the increased needs of the patients and was commissioned in 2013. A modern CT-Simulator, Treatment Planning System and High-Dose Rate Brachytherapy Unit are available for precise and highly conformal radiotherapy techniques.

Side effects of Radiation

  • Radiation of the mouth and throat area can cause both acute and chronic side effects, including:
  • Skin changes like a sunburn or suntan in the treated area that slowly fades away
  • Hoarseness
  • Loss of sense of taste
  • Redness and soreness or even pain in the mouth and throat
  • Chronic side effects are caused by long term exposure. Neural structures can only tolerate up to certain doses. Long-time exposure may lead to damage to the particular organ.
  • The key is giving lower dosages, all leading technology focuses on low dosage.

GKNM is associated with private and government insurance schemes and so everything is taken care of. The department is recognised for the PM relief fund, CM relief fund, travel (bus and train) concessions for the patient and an attender, sponsorship for waiver of bed charges.

Raksha is a palliative unit care for cancer patients. Where we give dormitory accommodation for free during the course of treatment.

We see in GKNM  around 3000 to 4000 new  cancer patients annually. Head and neck cancer patients number around 400 to 500 patients in a year.

Earlier people were not much aware of the disease and treatment was sought very late. But, things have changed for the better and more and more people seek treatment in time.

WHO says by 2020, cancer will be the leading cause of death. This is due to the change in life style and other factors. Prevention of predisposing factors, which are in our control, can actually bring down the incidence of the dreaded disease.

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Valavadi Narayanaswamy Cancer Centre, GKNM Hospital

  • 60 years of compassionate cancer care

On an average about 1300 Indians are diagnosed with cancer everyday.  Incidence of cancer in India is estimated to grow by 25% by 2020.  A diagnosis of cancer shatters the fabric of life of the affected person and his family.  The questions they ask themselves immediately are “How long will I live?  The next question very often is “Can I afford cancer treatment?”.

Cancer diagnosis and treatment has come a long way in the recent years.  The Valavadi Narayanaswamy Cancer Centre (VNCC) was established at G.K.N.M. Hospital in 1958 and continues to offer state of the art cancer care to the community.  At G.K.N.M. Hospital, we see around 3000 – 4000 new cancer patients every year.  We are one of the few cancer hospitals in Tamil Nadu to be part of the National Cancer Grid (NCG), a network of 153 cancer centres all over India.  Hospitals under the National Cancer Grid follow uniform treatment policies for various cancers.  This helps us offer evidence based world class cancer care to all our patients.

VNCC offers a wide spectrum of services to the community.  There is a great emphasis on prevention and early detection of cancer with cancer screening camps in the community.  We follow an organ based sub-specialization, one of the very few cancer hospitals in India to do so.  This helps us in keeping up with the rapid advances in cancer treatment, thereby enabling us to offer the best and the most recent options in cancer care.  All patients with cancer diagnosis are discussed in our multi-disciplinary tumour board, where we have radiation oncologists, surgical oncologists, medical oncologists, pathologists and radiologists.  This helps us individualize cancer care for our patients.  We offer cancer genetics counseling to people who have a family history of cancer.

Cancer treatment takes its toll not only on the patient but also his family.

Counselors from CCF work with cancer patients helping them cope with their diagnosis and help complete their treatment.  The breast cancer support group, the cervix club and the pediatric support group are a great source of strength and encouragement to patients undergoing cancer treatment.  Patient recovery is enhanced by our team of dietitians and physiotherapists providing holistic care.

For patients with terminal cancer, we believe in providing them with facilities to die with dignity, a basic human right.  We have a full-fledged pain and palliative care team to take care of these patients.  “RAKSHA”, our hospice, is oasis of calm and peace for palliative care patients.  A more recent addition to our team is our Home Care Services, where patients with chronic disease and patients requiring palliative care, are seen by our team in the comfort of their own homes.

The experience and expertise of the doctors working in VNCC is backed by an expert anaesthetic and nursing team and the latest technology which has enabled us deliver compassionate and comprehensive cancer care for the last 60 years.  We continue to strive towards offering quality cancer care to our community.

– Dr. Latha Balasubramani, Consultant Gynae Oncologist, GKNM Hospital.

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Radiation Therapy – all you need to know

What is radiation therapy?

Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. X-rays, gamma rays and charged particles are types of radiation used for cancer treatment.

How does radiation therapy kill cancer cells?

Radiation therapy kills cancer cells by damaging their DNA (the molecules inside cells that carry genetic information and pass it from one generation to the next). Radiation therapy can either damage DNA directly or create charged particles (free radicals) within the cells that can in turn damage the DNA.

Does radiation therapy kill only cancer cells?

No, radiation therapy can also damage normal cells, leading to side effects.

What are the types of radiation therapy?

  1. Like surgery, radiation therapy can be a local treatment; it affects cancer cells only in the treated area.
  2. If the area treated is broader, we say it is then a regional treatment.
  3. Rarely, the whole body is given radiation therapy for a systemic or total-body effect.
  4. Radiation can come from a machine (external radiation).
  5. It can also come from an implant (a small container of radioactive material) placed (either temporarily or permanently) directly into or near the tumor (internal or interstitial radiation).
  6. Some patients receive both kinds of radiation therapy.

Why do patients receive radiation therapy?

Radiation therapy is sometimes given with curative intent (that is, with the hope that the treatment will cure a cancer, either by eliminating a tumor, preventing cancer recurrence, or both). In such cases, radiation therapy may be used alone or in combination with surgery, chemotherapy, or both.

Radiation therapy may also be given with palliative intent. Palliative treatments are not intended to cure. Instead, they relieve symptoms and reduce the suffering caused by cancer.

What are the machines used in Teletherapy?

Olden days, the Cobalt 60 machine was used. Nowadays, a machine called Linear Accelerator (also called LINAC) which use electricity to form a stream of fast moving subatomic particles which creates high energy radiation that may be used to treat cancer.

What is Brachytherapy?

Internal radiation therapy:

Internal radiation therapy (brachytherapy) is radiation delivered from radiation sources (radioactive materials) placed inside or on the body.

How does Brachytherapy act?

In brachytherapy, radioactive isotopes are sealed in tiny pellets or “seeds”. These seeds are placed in patients using delivery devices, such as needles, catheters, or some other type of carrier. As the isotopes decay naturally, they give off radiation that damages nearby cancer cells.

Uses:

Doctors can use brachytherapy alone or in addition to external-beam radiation therapy to provide a “boost” of radiation to a tumor while sparing surrounding normal tissue.

Types of External Beam Radiation therapy:

3D CRT:

One of the most common types of external-beam radiation therapy is called 3-dimensional conformal radiation therapy (3D-CRT). 3D CRT uses very sophisticated computer software and advanced treatment machines to deliver radiation to very precisely shaped target areas.

Intensity-modulated radiation therapy (IMRT):

IMRT uses hundreds of tiny radiation beam-shaping devices, called collimators, to deliver a single dose of radiation. The collimators can be stationary or can move during treatment, allowing the intensity of the radiation beams to change during treatment sessions. This kind of dose modulation allows different areas of a tumor or nearby tissues to receive different doses of radiation.

Image-guided radiation therapy (IGRT):

In IGRT, repeated imaging scans (CT, MRI, or PET) are performed during treatment for accurate treatment delivery.

Stereotactic radiosurgery:

Stereotactic radiotherapy (SRS) can deliver one or more high doses of radiation to a small tumor.

Stereotactic body radiation therapy:

Stereotactic body radiation therapy (SBRT) delivers radiation therapy in fewer sessions, using smaller radiation fields and higher doses than 3D CRT in most cases. By definition, SBRT treats tumors that lie outside the brain and spinal cord. Because these tumors are more likely to move with the normal motion of the body, and therefore cannot be targeted as accurately as tumors within the brain or spine, SBRT is usually given in more than one dose. SBRT can be used to treat only small, isolated tumors, including cancers in the lung and liver.

Proton therapy:

External-beam radiation therapy can be delivered by proton beams as well as the photon beams described above. Protons are a type of charged particle.

Other charged particle beams:

Electron beams are used to irradiate superficial tumors, such as skin cancer or tumors near the surface of the body, but they cannot travel very far through tissue. Therefore, they cannot treat tumors deep within the body.

– Dr.M.Nagarajan, Director for R& D- VNCC, HOD – Radiation Oncology, GKNMH.

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12 Crore smokers & 3 Crore smokeless tobacco users worldwide

Cigarette smoking is estimated to cause more than 1 million cancer deaths annually worldwide. Lung cancer is the dominant cancer caused by smoking.  90% of Lung cancers are caused by smoking. Cigarette smoking also causes Carcinoma urinary Bladder, Oral Cavity, Pharyngeal, Oesophagal, Stomach, Pancreatic, Liver and Cervical Cancers. Second hand smoke causes Lung Cancer in   nonsmokers. Among the wives of smokers, the risk is increased by 20%. Workplace exposure to second hand smoke increases lung cancer risk in non smokers by 15%. Disease caused by tobacco includes Lung diseases like chronic bronchitis, emphysema leading to COPD, Heart Attacks, Stroke and Peripheral Vascular disease.

In India, smoking kills a million people every year. Tobacco has 4000 Chemicals, 63 of which have been proved to cause cancer. Researches show that 70% of the smokers want to quit the tobacco habit, but only 30% of them try quitting and only 3% succeed on their own. It requires more than just willpower to quit this deadly habit because nicotine is as addictive as heroine or cocaine. A majority of those seeking help to quit tobacco don’t require drugs. Rather behavioral therapies, education, tips to quit, motivation to change and relapse prevention counseling were deemed most appropriate for 69 per cent tobacco quitters.

Since smoking poses enormous health risks to individuals and their families, even modest improvement in the reduction smoking may translate into a significant change in public health.

Tobacco cessation clinic:

We at VN Cancer Centre, GKNM Hospital, in association with Coimbatore Cancer Foundation, started the Tobacco Cessation Program in November 2009. Over the last nine years, we have helped around 10,000 people lead a tobacco free life.

VANAVIL project

We have also started VANAVIL – No Tobacco and drugs program for schools and colleges. Under the program, we visit various schools in Coimbatore and educate them about the ill effects of tobacco with the help of Videos and pamphlets. We have conducted this program in 78 Government and private schools and educated around 28100 students about the ill effects of tobacco.

Tobacco Free Coimbatore

This is a project to create a tobacco free environment in Coimbatore. This was launched on 31st May 2017 by.A.Amalraj, Commissioner of Police. In collaboration with NCC students, the project aims to sensitize college students and community about the consequences of tobacco use and also promote tobacco cessation among smokers.

– Dr B. SIVANESAN, Consultant Medical Oncologist, Head Tobacco Cessation Clinic, VN Cancer Centre, GKNM Hospital.

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Advances in Head and Neck Cancer Surgery

Man’s face is his biography- Oscar Wilde

Men’s fashion is a recent fad and trends are dictated by hair style or beard style these days.  We spend a great deal of time and money to keep our face acceptable to the society we live in. Cancers in these areas can negatively affect the quality of life of patients. They can not only interfere with basic day-to-day functions like eating, breathing and speaking, but can also affect the aesthetics and one’s very acceptance in society.

Head and neck cancers, i.e., cancers arising from mouth and throat are among the commonest cancers in India. These cancers predominantly affect men and are usually caused by tobacco usage.

Using tobacco and alcohol increases the risk of these cancers by around 11 fold. At GKNM hospital we see around 400 new patients with head and neck cancer every year.

Treatment of these cancers usually require multiple modes of treatments and the best results are achieved by a collective effort of various experts. The aim of the treatment is not only to cure the cancer but also to ensure that the patient is able to lead a good quality of life.

Surgery plays an important role in the cure of head and cancers, where the visible tumors are removed completely. This usually results in a void which needs to be covered using a muscle and skin flap. Until recently these flaps were taken from the forehead or chest, which may give a poor cosmetic outcome. With advancements in surgical techniques, we in GKNM have moved towards a better and safer technique called ”Microvascular Free flap reconstruction”, wherein a piece of skin and muscle are taken from the forearm or leg along with the blood vessel and reconstructed at the operated site.

Free flap surgery is challenging, takes around 6-8 hours and requires an expert team work involving oncosurgeon, plastic surgeon, anaesthetist, post-operative nurse, nutritionist, physiotherapist and counsellors for an optimal outcome. Every patient is evaluated by an expert panel of oncologists (surgical, radiation and medical oncologist) in a multidisciplinary tumor board before deciding on the best treatment.

We have been doing such free flap reconstructions for the past 8 years and is the current standard of care across the world. The results have been very good both in terms of cancer control as well as good cosmetic outcome.

To summarize, head and neck cancers are preventable, easily detectable and definitely treatable and curable, if detected early. With a multidisciplinary approach, advanced surgical and radiation techniques, we are able to provide quality, state-of-the-art cancer care that GKNM has always stood for.

– Dr Mohanraj R, Consultant Surgical Oncologist, VN Cancer Centre, GKNM Hospital, Coimbatore.