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| Friday, 14 May 2004 |
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Cancer concerned Prof. Merille Perera [MBBS (Cey), DCP (Lond), FRCP (Edin), FCCP (Sri Lanka)] former Professor of Pathology of the Ruhuna University in an article to the HealthWatch on cancer, explains why the people should be cancer-concerned.
He goes on to say that cancer being generally a terminal sickness, with immense sufferings to the affected, is generally believed to be by the people as a disease with no possible cure. He wants to tell the public that this view is not alltogether right, because if detected early even malignant tumours can be surgically removed and the patient can be completely cured of the sickness. This is why people should be concerned with cancer, know and understand about the disease. Tumour behaviour and spread In this regard Prof. Perera writes: A benign tumour, by nature of its character, is confined to the site of origin, merely prodding and pushing the tissues adjacent. It is harmless by itself, unless it impinges on a vital organ such as the heart or occurs in vitally specific areas, say in the cardiac or respiratory centres in the medulla of the brain. But the behaviour and growth pattern of malignant tumour is quite distinctly different as, after it gets an initial hold on a tissue, the cancer propagates itself to distant sites by diverse mechanisms. Just over a hundred years ago, Stephen Paget of UK (not James Paget of Paget's disease fame) collected post-mortem records of 735 patients who had died of breast cancer and found that the majority of the metastases ('seedlings') were in the liver and brain, and thus he concluded that tumours were predisposed to see in certain tissues. He wrote: "When a plant grows to seed, its seeds are carried in all directions, but they can only live and grow on congenial soil." It came to be known as the 'seed and soil' theory. James Ewing of USA, forty years later, suggested that tumours went to particular organ not because of the seed and soil effect, but depending on the routes of lymphatic and venous drainage of the primary tumour, wherever it originates. How do tumours spread? A very important feature of a tumour is the local spread or metastatic spread. Permanent cure possible Even a malignant tumour establishes itself locally for a while in and around the site of origin. This is the stage amenable to surgery. One is lucky to have a cancer detected at this stage because a permanent cure is possible without recourse to chemotherapy or irradiation. Or, if at all, only a mild post-operative course, that does not produce side effects, is sufficient for radical cure. Investigate procedures in cancer diagnosis Physical examination A physical examination, both local as well as general, follows after taking a history from the patient regards the nature and location of a lump, and its duration. He may be able to furnish details that relate to making a diagnosis. By far a relevant aspect of cancer diagnosis is the physical examination of the tumour. Time-honoured methods are: Inspection and Palpation of the tumour are the most important of all. The size, shape and colour of a tumour are gauged on inspection. Any recent changes? Palpation would reveal its consistency, whether solid or cystic. Fluctuation elicits this. The boundaries should be defined, whether the tumour is regular or irregular. Measurement could be recorded in centimetres. (usually in 3 dimensions). The temperature of a lump could be felt on the back of the hand, whether warm or cold. Some tumours need to be auscultated, specially if they are pulsatile. Attachments to skin and underlying structures should be assessed as it is very relevant. Investigative procedures The valuable information gained by a simple examination of a lump cannot be ignored, as all too often a clinical diagnosis is clinched on the basis of an inspection and palpation. Next, a series of tests will follow, to confirm or refute a diagnosis of whether a tumour is benign or malignant. A precise diagnosis can be made only after various investigations are made, which are a legion. These may include a fine-needle aspiration cytology, a core tissue biopsy, full blood checkup, chest x-ray, ultrasound exam or a bone survey scan, mammography or body imaging etc. The surgeon in care of a patient will have to decide which tests are appropriate to make a final diagnosis, in keeping with the patient's condition, and bearing in mind that minimum discomfort should be caused to him. Fine-needle aspiration cytology The technique is called FNAC, for short. The procedure is to insert a fine needle, with or without local anaesthesia, into the lump concerned and an aspirate obtained of fluid or cells from a lump. It is a painless procedure of short duration. Samples are smeared on glass slides, and subjected to microscopic examination by a trained pathologist, after staining with chemical dyes. Result is available without much delay. Tissue biopsy This is a very crucial test before major surgery is undertaken. A core of tissue is taken through a wide-bore needle into a solution of formal-saline for fixation of tissue, and subsequently after a rather elaborate dehydrating procedure of passing through various strengths of alcohol, are embedded in wax and tissues finely sectioned by a mechanical cutting instrument called a microtome. Later, thin sections are placed on glass slides and stained before microscopic evaluation. At an open operation, a wedge of tissue, say from a breast, could be removed and frozen, urgently cut and stained, and the result revealed whilst the surgeon awaits in the operating theatre to decide on the next course of action. ******************* Italian study reveals: Cancer cost cutting possibility with nutrition An Italian study has revealed the cost cutting possibility of operating on cancer patients with pre and post-operative nutrition feeding. The trial had been carried out at the Department of Surgery at the University of Milano-Bicocca Monza, Italy in May, 2003. A report of this study, which could be immense benefit to Third World countries like Sri Lanka, burdened with escalating health care costs in cancer treatment has been sent to our Medical Advisory Panel for use in this page, by a doctor who had attended the 16th AGM of the Surgical Infection Society, Europe held in May last year, where Dr. Luca Gianotti of the Milano University gave a detailed account of this trial. Health care costs Dr. Gianotti has stated at this meeting "Randomised trials have shown that pre-operatively loading elective cancer surgery patients with immune enhancing substrates in an oral formula for five days and continuing therapy by infusion for 7 days after surgery results in significant reductions in postoperative infections and length of hospital stay in patients undergoing gastro intestinal surgery for cancer, with a subsequent significant reduction in health care costs. Dr. Gianotti further states:- Preoperative administration of an oral supplement containing immune-enhancing nutrients gives a boost to patients' immune system that helps them to fight off postoperative infections, so they spend less time in hospital. New data presented at the recent 16th annual meeting of the Surgical Infection Society Europe (May 29 - 31, 2003) in Cernobbio, Italy, Dr. Luca Gianotti from the Department of Surgery at the University of Milano-Bicocca, Monza, Italy, showed that major operations for cancer of the gastrointestinal tract are still associated with a high risk of complications and a high consumption of health care resources. Surgical trauma increases levels of proinflammatory cytokines and lowers host defense mechanisms. But administration of oral IMPACT(R) an enteral immune-enhancing drink, (supplemented with arginine, n-3 polyunsaturated fatty acids and ribonucleotides) is able to modulate the immune and inflammatory responses altered by surgical trauma, upregulating gut microperfusion and oxygen metabolism. (1) Reduction in complication Post-hoc analysis of these data suggested that even patients who were unable to comply with postoperative immununotrition benefited from a reduction in complications. So to determine whether preoperative treatment was as effective as perioperative treatment in reducing postoperative complications. Dr. Gianotti conducted two trials in patients with gastrointestinal cancer comparing both approaches with control group who received no additional immune-enhancing supplementation to normal diet. One trial enroled malnourished patients (n=150) (4) the other enroled well-nourished patients (n=305). (5) Published results showed The published results showed that in malnourished patients (those who had lost more than 10 per cent of body weight in the previous 6 months) patients in the control group had significantly more postoperative complications than those treated preoperatively, while those treated before and after surgery even fewer. This was reflected in patients total length of hospital stay, which was significantly shorter in the preoperative (13.2 days) and perioperative (12.0 days) groups than in the control group (15.3 days). But in well-nourished patients, oral preoperative supplementation showed similar results to perioperative immune-enhancing supplementation, and both were superior to the control approach: * Incidence of postoperative infections was 14 per cent in the preoperative group and 16 per cent in the perioperative group, but over 30 per cent in the control group (P=0.006 vs. preoperative; P=0.02 vs. perioperative). * Length of hospital stay was 11.6 days in the preoperative group, 12.2 days in the perioperative group, and 14.0 days in the control group (P=0.008 vs. preoperative and P=0.03 vs perioperative). Whether malnourished or well-nourished Dr. Gianotti explained: Preoperative feeding 5 days prior to surgery modulates the host immune defense mechanisms sufficiently to avoid surgical depression of the immune system, and thus to fight off postoperative infections. Whether patients are malnourished or well-nourished, preoperative supplementation with an immune-enhancing formula will ensure that patients are fit for surgery, he said. But in well-nourished patients we can avoid possible side-effects of enteral feeding, such as nasojejunal tube clogging or removal, abdominal cramps and save the costs of providing postoperative immunonutrition. Real cost savings But the real cost savings from this preoperative immune-enhancing supplementation strategy emerged when he added up the costs of managing postoperative complications (obtained from the Italian Ministry of Health) in this trial. Unsurprisingly, for patients with no complications the cost was lowest in the control group, but for patients with complications the cost per patient was lowest in the preoperative treatment group. Adding together the costs of nutrition plus the costs of managing both complicated and uncomplicated patients, Dr. Gianotti found the total costs as: * 723.368 Euro for control group |
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