Cancer: The Emperor of Maladies

Cancer has been rightly called "The Emperor of Maladies." Hippocrates was the first to use the terms carcinomas, and carcinoma. In Greek, these words refer to a crab and more often than not, cancer cells have finger-like projections. It is wrongly assumed that cancer is known as the 'crab disease' because of its firm grip on the life of a patient.

Cancer-Causing Cells:

• The medical term for any type of cancer is neoplasm. It refers to the proliferation of an abnormal mass of cells. These cells are called dysplastic cells.

• They are different from normal cells and in that they are poorly differentiated.

• This means that they do not bear any resemblance to normal cells, whereas well-differentiated cancer cells bear some resemblance to normal cells.

• Poorly differentiated cells are also called undifferentiated cells. As a rule of thumb, poorly differentiated cells spread and invade tissues more rapidly by a process called metastasis.

• Cells in the human body have a limited lifespan and once they are done with their functions, they undergo programmed cell death. This physiological process is called apoptosis.

• Cancer is the result of a faulty apoptotic mechanism. That is, cells that are normally programmed to die after a certain time do not die and instead persist.

• When an injury is incited in the form of toxins and repeated inflammation, these cells become cancerous or malignant.

• Malignancy may also be due to faulty DNA repair mechanisms.

• Whenever a cell is injured, several repair genes are called into play.

• These are further classified into nucleotide excision repair genes and mismatch repair genes.

• To give the details of the other types of DNA repair genes is beyond the scope of this article. Suffice it to say that when these repair genes fail to repair the inciting event, say an inflammation or a toxin-related injury, the cells do not undergo apoptosis and instead become malignant.

Carcinogenesis:

• Carcinogenesis is a multi-step process.

• It comprises inherited cancer syndromes, familial components, and complex interactions at the molecular and cellular levels.

• Genes that promote the cell growth are called protooncogenes, and those that suppress cell growth are called tumor suppressor genes.

• In physiological conditions, an equilibrium exists between the protooncogenes and the tumor suppressor genes.

• Cancer is the result of a sort of disequilibrium between these two regulatory mechanisms.

• As a tumor enlarges in size, new blood vessels keep sprouting all throughout and feed the cancer cells. This emergence of new blood vessels is termed angiogenesis.

Grading and Staging of Cancer:

• Differentiation is used as a parameter to grade cancer.

• Grading is done on the basis of how quickly cancer cells spread or invade neighboring tissues.

• Grading refers to the degree of abnormality seen in the tissue under the microscope.

• Often, the terms grading and staging are interchanged, and are wrongly done so. Grading is not the same as staging.

• Staging refers to the size of the original tumor, also called a ''primary'' tumor.

• The cells that have spread to other tissues to form abnormal masses are called secondaries.

Treatment of Cancer:

Treatment of cancer has come a long way.

• Molecular profiling, targeted gene therapy, receptor profiling are some of the advances in the field of cancer chemotherapy.

• A plethora of drugs is available to treat the disease at various stages.

• The term neoadjuvant chemotherapy refers to shrinking the tumor before surgical resection.

• A class of drugs has emerged called "MABs," which means monoclonal antibodies. Some examples include Trastuzumab (Herceptin), Cetuximab, Alemtuzumab, etc.

Side Effects of Chemotherapy:

• Chemotherapy is a necessary evil. It comes with its fair share of side effects like nausea, vomiting, blisters in the mouth, mucositis, hair fall, extreme fatigue, and depression.

• The most common side effect of chemotherapy is CINV which stands for chemotherapy-induced nausea and vomiting.

• Surprisingly, there are drugs to counter CINV too.

• Aprepitant and Ondansetron are commonly used to counter CINV.

Psycho-oncology:

• Having had a brief introduction to the basic terminologies, it is important to focus on the deleterious effects cancer has on the patient's functionality. A new field has emerged in recent years and is titled psychooncology.

• This field focuses on designing psychological interventions which help in tiding over the cancer crisis.

• These interventions may be as simple as talking to someone close, discussing the ongoing treatment and the available future options. All this requires is an empathetic listener.

• This process serves as a sort of catharsis and provides emotional ventilation.

A similar but more refined approach is used by therapists in Cognitive Behavioural Therapy. Other psychological interventions include hypnotherapy, talk therapy, and family therapy. Each of these therapies needs to be individualized, as there is no one-size-fits-all treatment.

Effects of Cancer on an Individual:

• The quality of life of a patient with cancer is severely hindered.

• Studies have found disturbances in the domains of sleep, mood, employment, finance, and anxiety levels.

• All these factors contribute to a decline in socio-occupational functioning.

• Cancer chemotherapy can itself result in secondary depression.

• It is advisable to liaise with a psychiatrist for assessment and appropriate intervention.

• The primary care physician needs to bear in mind the drug-drug interactions between anti-depressants and drugs used in chemotherapy. It is vital to rope in an expert in the field of mental health, and such decisions are best left to professionals.

Prevention of Cancer:

• The aphorism prevention is better than cure is very apt with regard to cancer. A healthy lifestyle offsets what is called ''bad genes," and turns on ''good genes."

• Studies have consistently shown that the only way to prolong longevity after the age of forty is via caloric restriction.

• US based preventive medicine expert Dr. Dean Ornish in his seminal work on the prevention of cancer has categorically stated that a healthy lifestyle turns off the bad genes and switches on the good genes.

• He advocates a plant-based diet, adequate sleep, curbing stress, spending more time with family, and having good interpersonal relationships as the necessary wherewithal to prevent and combat cancer.

• Brisk walking for forty-five minutes per day for 5 to 7 days a week is also beneficial. As it is a non-weight bearing exercise, walking is completely injury free.

• Another preventive measure would be to avoid all forms of radiation as and when possible. However, this is easier said than done. Cardiologists, orthopedic surgeons, and all those involved in vessel intervention operate under fluoroscopic guidance. This itself exposes them to sufficient radiation. One particular study found 6 cases of neuroblastoma in cardiologists in the US.

• Radical surgeries (for example, removal of breasts - mastectomy) are not needed by one or all. Neither is genetic testing recommended to all and sundry. It may be useful in those who have a strong family history of cancer, those who are constantly exposed to radiation, and those whose other family members have had cancer at an early age. In such cases, advanced genetic testing as a preemptive measure is recommended.

• However, screening for any kind of cancer should start in everyone aged over forty years.

• Men aged over forty five years should get their Prostate-Specific Antigen (PSA) levels done annually. It is a biomarker to detect prostate cancer in the early stages.

• Women above forty years, on the other hand, need to undergo annual mammograms and PAP smears. The importance of breast self examination (BSE) cannot be stressed more in this regard.

All said and done; given all the advances in medical science to detect cancer early, cancer can still be a curse. It may, and it will escape early detection in a vast majority of cases. This is because people are still at a nascent stage to map every possible mutation. Cancer, after all, is a permutation and combination of mutations. I came, I became a mutant, and I conquered, is what the cancer cells seem to be crying hoarse. Hope is something that helps everyone to look at a better future. And hope is necessary for doleful amounts in tiding over a cancer crisis.