Advanced Linear Accelerator (LINAC, Elekta Synergy Platform) with Triple Energy (4MV, 6MV & Whole range of Electrons)

Internsity Modulated Radiotherapy (IMRT) for avoidance of radiation dose to normal structures & high radiation dose to tumor

3-Dimensional Conformal Radiotherapy (3D-CRT)

Conventional & Palliatrive Radiotherapy

Electronic Portal Imaging Device (EPID verification for Set-up accuracy) State of the art Mould Room for accurate positioning & immobilization

CT-simulation and computerised treatment planning with MRI/PET-CT fusion

High Dose Rate (HDR) Brachytherapy

Tumour Board comprising of Radiation Oncologistis, Surgical Oncologists & Medical Oncologists for deciding plan of treatment using multimodality approach (Evidence Based Medicine).

Departmentof RadiationOncologySPECIAL FACILITIES

COMPREHENSIVE CANCER CARE TODAY

Vol. I Issue I

SPECIAL ISSUE ON CANCER

Care PlusA Monthly New

From Max Super Speciality Hospital, Phase VI, Mohali

A NABH Accredited Hospital

sletter

Cancer is curable or at least controllable for many years provided the treatment is delivered by a team of experts in cancer treatment working with fine coordination.

Cancer is not curable without treatment which makes it different from other diseases.Cancer is an uncontrolled multiplication, starts with of a few body cells which keep on dividing and leading to a growth which finally may spread to nearby structures as well as to other parts of body. These cell growths are of no use but affect the other normal organ functions. There are no specific symptoms of cancer. It all depends on the site, extent and organ affected by these growths. Cancer is different from other diseases as it is almost never cured without treatment. Cancer is not a single disease but a group of more than 100 types, subtypes and stages of diseases. The biological behavior varies from very slow growing cancers where patient may live for years even without treatment and to some very aggressive types where the survival is in weeks only. Thus, delay in consulting with a specialist due to frightening or social stigma is of no use like many other problems.In most of the cases, cancer treatment is not an emergency as the disease usually starts months to years before clinical symptoms and diagnosis. So, before starting the treatment, a thorough investigation and diagnostic workup under guidance of a cancer specialist or a team of specialists is most helpful for best treatment and best results. A delay of few days in this process hardly matters.About 60 years back, surgery was the only major treatment available for cancer treatment. During later half of last century a lot of work has been done on cancer treatment and other treatment modalities like chemotherapy, radiotherapy, hormonal therapy and immunotherapy have emerged with vast contribution in cancer care. Appropriate combinations of these modalities have increased the cancer cure rate many fold during last couple of decades with much reduction in side effects. Today, along with cure of cancer, the quality of life is also considered as a part of cancer management.In today’s scenario, the management of cancer is Multimodal Treatment (i.e. more than one treatment modalities and experts) in more than 70% cases. For example, most of the patients of breast cancer are treated with a combination of surgery, chemotherapy, radiotherapy and many of them also require further hormonal and immunotherapy. The combined approach during last few decades has made this highly incurable cancer to a highly curable cancer. Same is true in most of other cancers also.

Dr. Vinay Kumar(MBBS, MD), Radiation Oncology

LUNG CANCER is the second most common cancer and the leading cause of cancer deaths for men and women. Lung cancer represents 15% of all cancer diagnoses and 28% of all cancer deaths.

DIAGNOSISDoctors use many tests to diagnose cancer

and find out if it has spread from the lung. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer.

Biopsy A biopsy is the removal of a small amount of tissue for examination under a microscope. The

sample removed from the biopsy is analyzed by a pathologist (a doctor who

specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to

diagnose disease). If cancer cells are present, the pathologist will determine if it is small cell

lung cancer or Non Small Cell Lung Cancer, based on its appearance under the microscope.Common

procedures doctors use to obtain tissue for the diagnosis and staging of lung cancer are Sputum cytology, Bronchoscopic biopsy, Needle aspiration/core biopsy from lung mass, evaluation of fluid in lungs, thoracoscopic or Mediastinoscopic biopsy.

IMAGING TESTSIn addition to biopsies and surgical procedures, imaging scans are vital to the care of people with lung cancer. However, no test is perfect, and no scan can diagnose lung cancer. Only a biopsy can do that. Chest x-ray and CT scan, PET scan results must be combined with a person’s medical history, a physical examination, blood tests, and biopsy information to form a complete story about where the cancer began and whether or where it has spread.

TREATMENTThere are four basic ways to treat lung cancer: surgery, radiation therapy, chemotherapy, and targeted therapy

SURGERYSurgery is the removal of the tumor and surrounding tissue during an operation. A surgical oncologist is a doctor who specializes in treating cancer using surgery. For lung cancer, a thoracic surgeon is specially trained to perform lung cancer surgery. The goal of surgery is the complete removal of the lung tumor and the nearby lymph nodes in the chest. The tumor must be removed with a surrounding border of normal lung tissue (called the margin).

ADJUVANT THERAPYAdjuvant therapy is treatment that is given after surgery to lower the risk of the lung cancer returning. Adjuvant therapy includes radiation therapy and chemotherapy. Adjuvant therapy is intended to eliminate any lung cancer cells that may be lingering in the

PREVENTIONThe most important way to prevent lung cancer is to avoid tobacco smoke. People who never smoke have the lowest risk of lung cancer. People who smoke can reduce their risk of lung cancer by stopping smoking, but their risk of lung cancer will still be higher than people who never smoked.

SCREENINGRecently, a large study called the National Lung Screening Trial showed that, in patients who are current or former heavy smokers, the use of a screening test called a low-dose helical (or spiral) computed tomography (CT or CAT) scan decreases the risk of death from lung cancer by 20%. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. CT scanning is not recommended for every smoker. Doctors still need to prove that screening everyone at risk for lung cancer reduces rates of death from lung cancer in the general population.

SYMPTOMS AND SIGNSPeople with lung cancer may experience the following symptoms or signs. Sometimes people with lung cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

• Fatigue • Cough • Shortness of breath • Chest pain • Loss of appetite • Coughing up phlegm or mucus • Hemoptysis (coughing up blood)

Other than treatment, a lot of researches in the field of investigations like CT scan, MRI, PET scan in imaging and immunohistochemistry in pathology has become a revolution in diagnosis, early detection and staging of the cancer.The final treatment plan should be based on EBM (Evidence Based Medicine) and with the help of International Guidelines, like NCCN (National Comprehensive Cancer Network), NCI (National Cancer Institute) and many others.After proper diagnosis and staging workup, the most appropriate method for taking a decision for the best treatment in a particular case is tumor board. In Tumor Board, a team of experts in different fields, specially cancer surgeon, medical oncologist, radiation oncologist, radiologist and pathologist make a final line of treatment. Max Superspeciallity Hospital, Mohali has a complete team of cancer specialist, including Cancer surgery, Chemotherapy and Radiotherapy along with most advanced technological infrastructure.Radiotherapy has emerged as an important mode of treatment during last 20 years since advances in technology like IMRT, IGRT, 3DCRT and HDR Brachytherapy. With these techniques, a targeted high dose of radiation can be given to cancer site while the nearby normal structures can be avoided from radiation. In this way the cure rate has increase with very high decrease in side effects.In today’s scenario various printed and electronic media helps in updating the experts and international guidelines are available based on evidence based medicine (EBM). In EBM, the treatment decision is based on most recent authentic scientific research literature and articles from renowned cancer centers, worldwide, with their recommendations, again based on their experience and research on large number of patients treated by them during last decades.Max Super Specialty Hospital at Mohali provides a comprehensive cancer care including all the recent modalities (Cancer Surgery, Cancer Chemotherapy & advanced Radiotherapy) under one roof.Department Of Radiotherapy is well equipped with all the latest state of art technologies like Linear Accelerator with Triple Energy Photons, full range of Electrons, Amorphous Silicon Electronic Portal Imaging (EPID) with IMRT, 3Dimentional RT and conventional RT. The Center is also equipped with HDR (High Dose Rate) Brachytherapy, 16 Slice GE CT Scan with LAP Laser system for CT Simulation and advance Mould Room.

Motto of Cancer Team at Max Hospital, Mohali: No cancer patient should be deprived

of the best treatment available today.

Dr. Sachin GuptaMedical Oncology &Hemato-Oncology

body. It may decrease the risk of recurrence, though some risk will remain.

RADIATION THERAPYPatients with lung cancer are treated with radiation therapy for curative and also palliative purposes. Radiotherapy involves use of rays to kill cancer cells. Radiotherapy has many advances in present times and techniques like IMRT, IGRT, SBRT have improved the responses and at the same time decreased side effects.

CHEMOTHERAPYChemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. A patient may receive one drug at a time or combinations of different drugs at the same time. Newer chemotherapy treatment plans cause fewer side effects and are as effective as older treatments. Chemotherapy has been shown to improve both the length and quality of life for people with lung cancer of all stages.

TARGETED THERAPYTargeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells, usually leading to fewer side effects than other cancer medications.

Anti-angiogenesis therapy Bevacizumab is a specialized drug given in combination with chemotherapy for lung cancer. Bevacizumab blocks the formation of new blood vessels (called angiogenesis), which is necessary for a tumor to grow and spread. The risk of serious bleeding for patients taking bevacizumab is about 2%.

Epidermal growth factor receptor (EGFR) inhibitors. An EGFR inhibitor is a type of targeted therapy. Researchers have found that drugs that block EGFR may be effective in stopping or slowing the growth of lung cancer.Cetuximab is a specialized drug given along with chemotherapy to treat lung cancer, especially when treatment with bevacizumab is not recommended. It is given intravenously. The side effects of cetuximab include rash and allergic reactions.Erlotinib is another drug that blocks the EGFR. This drug has been shown to work better than chemotherapy if the lung cancer has a mutation in the EGFR gene. Gefitinib is another drug that blocks the EGFR. Another targeted drug Crizotinib is available for lung cancer patients who have a special mutation EML4-ALK positive on testing their biopsy.

found that drugs that block EGFR may be effective in stopping or

Cetuximab is a specialized drug given along with chemotherapy to treat lung cancer, especially when treatment with bevacizumab is not recommended. It is given intravenously. The side effects of cetuximab include

Erlotinib is another drug that blocks the EGFR. This drug has been shown to work better than chemotherapy if the lung cancer has a mutation in the EGFR gene. Gefitinib is another drug that blocks the EGFR. Another targeted drug Crizotinib is available for lung cancer patients who have a special mutation EML4-ALK positive on testing

Max Super Speciality Hospital, Mohali is empanelled by ECHS, ESIC,Haryana Govt and all Major TPA’s & Corporates for Oncology Treatment.

HEREDITARYBREAST CANCERBreast cancer is most common cancer among women worldwide and second

only to cervical cancer in india. 1 out of 8 among all women can expect to develop breast cancer in their lifetime. Most breast cancers occur sporadically, but because it is a common disease, about 20% have positive family history. Hereditary breast cancer is the one with identifiable hereditary predisposition. Approximately 5% to 10% of all women with breast cancer may have hereditary breast cancer. Mutations of BRCA1 (chromosome 17q21) and BRCA2 (chromosome 13q12,13q13) are responsible for 90% of hereditary breast cancer. Other genes mutations implicated for hereditary breast cancer are PTEN, p53, MLH1, MLH2 and STK11.

BRCA1 and BRCA2 mutationsSpecific mutations of BRCA1 and BRCA2 are transmitted as autosomal dominant trait. These are more common in women of Ashkenazi Jewish ancestry. The estimated lifetime risk for developing breast cancer in women with a BRCA1 or BRCA2 mutation is 40% to 85%, and the risk for developing bilateral breast cancer is 20% to 40%. Mutations in either gene also confer a 20% to 40% increased

KIDNEY CANCERS ARE FAST GROWING TUMORS, ACCOUNT FOR 3% OF ALL CANCERS IN HUMAN.The most common variety is Renal Cell Carcinoma (RCC) – ‘Clear Cell’ being predomi-nant histological type (75%). Yearly about 10 cases of RCC per 1 lakh population detected, mostly over 50 years, twice in male than female.

Familial cancers (5%, VHL syndrome) present at younger age, with multiple tumors. Smoking increases the risk by 2 folds; as is chronic exposure to asbestos and cadmium.50% RCC are detected incidentally. Usual symptoms are flank pain, hematuria, feeling of lump or heaviness. Constitutional symptoms (fever, tiredness, loss of weight & appetite) and paraneoplastic syndrome occur in 30%. CECT and MRI are main stay of diagnosis (specificity 95%) and FNAC is routinely not required.

lifetime risk for developing ovarian cancer.

Indications for Genetic TestingWhether to undergo genetic testing for BRCA1 and BRCA2 is a complex decision and has implications on individual as well as family members. Genetic testing is available commercially. All patients should undergo genetic counselling before the test.The indications for genetic testing for breast cancer and ovarian cancer are as follows:• Two or more family members with breast and/or ovarian cancer at

age less than 50 years• Breast cancer and or ovarian cancer at a very young age• Known BRCA1 or BRCA2 mutations in a family member• Same patient being diagnosed with both breast cancer and ovarian

cancer• One or more family members younger than 50 years with breast

cancer and having Ashkenazi Jewish ancestry• Patients with ovarian cancer having an Ashkenazi Jewish ancestry.

Management of BRCA mutation carriersIf the test is positive patients have following options:• Intense screening using mammogram or magnetic resonance

imaging (MRI)• Chemoprevention using tamoxifen may be considered• Bilateral prophylactic mastectomy, which could prevent breast

cancer in 90% to 100%Prophylactic oophorectomy alone reduces breast cancer by 50%.

Dr. Sunandan SharmaSurgical OncologistMCH, Onco Surgery

Dr Sananda Bag Consultant, Urology &Renal Transplant

For any query please contact us at: Contactusatmohali@maxhealthcare.com

Surgical excision is the mainstay of treatment, is curative for kidney-confined cancers and solitary liver or lungs metastasis. For small (<4 cm), polar / exophytic tumors partial nephrectomy is equally beneficial as radical nephrectomy and reduces risk of kidney failure. For tumors extending to IVC or right atrium, removal of tumor thrombus with/without excision of IVC (under cardiopulmonary bypass in atrial tumors) has been advocated, with good long term result. Radiofrequency ablation (RFA) and Cryo-ablation have shown promising results in patients unfit for surgery, for tumors <3 cm and for multiple liver secondary. Biological / Immuno Therapy : In selected good or intermediate risk patients with advanced / metastatic Clear Cell RCC, Tyrosine Kinase Inhibitors have shown encouraging results in both adjuvant and neoadjuvent settings. The median PFS with Sunitinib and Pazopanib has been up to 11-12 months in 30-40% of patients. Prognosis: 5 years disease free survival with surgery alone [Open / Laparoscopic, Partial / Radical Nephrectomy] has been >95% for T1 (< 7 cm), 85-90% for T2 and 40-70