What is cancer?

The normal cells in the human body grow and divide and also die over time. All this physiological mechanisms are kept under check. Cancer develops when this cells grow and divide rapidly in an uncontrolled manner and spread to adjacent and distant tissue eventually killing the host.

What causes cancer?

Most common cancers in India are caused by tobacco chewing(oral cavity), smoking(lung), consuming alcohol (liver cancers) and infections like HPV (cervival cancer).  Most of the cancers in human body have some associated risk factors which will be covered in detail during individual cancer discussion.

Who gets cancer?

Any individual can get cancer with or without the presence of above mentioned risk factors. Some cancers like blood cancer, lymphomas, thyroid cancers are common in the very early age group and the rest of cancers in elderly population. In western population cancers are seen in elderly people ( age group more than 50-60 yrs) but in India cancers are occurring early for example average age of indian females getting breast cancer is around 40-50 yrs and many cases are even detected as early as 25 to 30 yrs and so is the case for rectal and gynecological cancers.

Is cancer treatable?

Cancer is curable completely in early stages and as the stage increases the survival decreases. So early diagnosis and proper treatment can cure cancer completely.

Cancer has how many stages?

Cancer has 4 stages. Stage I being the earliest and stage IV being the last. Each stage is further sub classified into subgroups.

What are cancer symptoms?

Different cancers have different symptoms. Like lump in the breast or nipple discharge for breast cancer, ulcer in the mouth or on tongue with or without pain for oral cavity cancers, blood in stools with pain, diarrhea or constipation for colon and rectal cancers, neck swelling for thyroid cancer, jaundice for pancreatic and billary tract cancer, swelling with or without pain for sarcoma usually seen in the legs, hands and back, cough with bloody sputum and breathlessness in lung cancer etc.

What should I do if myself or anyone known to me develops such symptoms?

Meet a doctor preferably an oncologist as soon as possible and get evaluated for your presenting symptoms

Individual cancers are dealt separately

A cancer that develops in the large intestine (large bowel) is known as colon cancer.

How does colon cancer develop?

Colon cancer starts when cells in the colon start to multiply in an uncontrolled fashion, first growing locally and then spreading to mesenteric lymph nodes and later to other parts of body most commonly peritoneum, liver and lungs.

What is a colon and what are it parts?

The food we eat is processed in the body primarily by the small intestine and later by the large intestine so that all the important nutrients get absorbed and the waste material is excreted as stools. The colon is divided into the caecum, the ascending colon, the transverse colon, the descending colon and the sigmoid colon. The large intestine ends as rectum into which stores the stools temporarily before defecation.

What causes colon cancer?

  1. The exact cause for development of colon cancer is not known yet but there are multiple risk factors which increases the chance for development of colon cancer as mentioned below
  2. Polyps: There are multiple types of precancerous polyps that are seen in the large intestine. They are i) Adenomatous polyps – tubular/ villous (most common premalignant), ii) Hyperplastic polyps (rarely become malignant) and Inflammatory polyps (may become malignant).
  3. Family history and Genetic causes: Inherited gene mutations that increase the risk of colon cancer can be passed through families. This mutations genes are responsible for only a small percentage of colon cancers. Inherited gene mutations does not mean that the cancer is inevitable, but it increase an individual’s risk of cancer development significantly. The most common forms of inherited colon cancer syndromes are: i) Hereditarynonpolyposis colorectal cancer (HNPCC) also called Lynch syndrome were there are very few polyps in the colon which may turn into cancer. ii) Familial  adenomatous polyposis (FAP) – there are thousands of polyps in the colon and rectum which eventually turn malignant around age 40.
  4. Age is an important risk factor for colon cancer. It is more common in older population with age grouparound 50yrs and above but there is a significant increase in incidence of colon cancer in younger population with age group as early as 20 -25
  5. Association between diet and increased colon cancer risk – a typical Western diet with high fat intake, red meat, processed meat and low in fiber increases the risk most probably by altering by affecting the microbes that live in the colon. So to avoid colon cancer a diet high in fiber content and vitamins is advisable.
  6. Other risk factors – colon cancer is more likely to occur in people with sedentary lifestyles, obese people, smokers and alcoholics. This are changeable factors and a healthy life style may decrease the risk of colon cancer. Few metabolic diseases like Diabetes, acromegaly (a growth hormone disorder), Chronic inflammatory diseases of the colon like ulcerative colitis, and Crohn’s disease all increase the risk of colon cancer.
  7. A personal history of colorectal cancer or polyps increases the risk for colon.
  8. Prior history of radiation treatment for other cancers cancer

What are the tests required to evaluate colon cancer?

The following tests are required to diagnose and evaluatecolon cancer:

  1. Complete Colonoscopy and biopsy: A scope is inserted through the anus and all the parts of colon till the caecum are seen with a scope. If any lesion are seen in the colon a biopsy is taken and if any polyps are seen, they can be removed. Histopathology examination of the removed specimen helps cancer confirmation.
  2. Local and metastatic evaluation: a Contrast Enhanced CT scan of the Thorax, Abdomen and Pelvis is required to evaluate the local extent of disease and also the disease spread. MRI and PETCECT are rarely required and are done as indicated.
  3. Carcinoembryonic antigen- helps in diagnosis, prognosis and follow up.
  4. Routine blood investigation to asses’ fitness of the patient for treatment.

What are the symptoms of colon cancer?

Colon cancer is usually asymptomatic in earlier stages. Late stage colon cancer have varied symptoms which are common to many benign disease. The signs and symptoms of colon cancer include:

  1. A change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool that lasts longer than four weeks.
  2. A common symptom of colon cancer is bloody stool or black color stool or both.
  3. Persistent abdominal discomfort, such as cramps, gas or pain
  4. A feeling that your bowel doesn’t empty completely
  5. Weakness or fatigue
  6. Unexplained weight loss

Contact a doctor (preferably an oncologist) if you experience above symptoms.

What are the tests required to evaluate colon cancer?

The following tests are required to diagnose and evaluatecolon cancer:

  1. Complete Colonoscopy and biopsy: A scope is inserted through the anus and all the parts of colon till the caecum are seen with a scope. If any lesion are seen in the colon a biopsy is taken and if any polyps are seen, they can be removed. Histopathology examination of the removed specimen helps cancer confirmation.
  2. Local and metastatic evaluation: a Contrast Enhanced CT scan of the Thorax, Abdomen and Pelvis is required to evaluate the local extent of disease and also the disease spread. MRI and PETCECT are rarely required and are done as indicated.
  3. Carcinoembryonic antigen- helps in diagnosis, prognosis and follow up.
  4. Routine blood investigation to asses’ fitness of the patient for treatment.

How is colon cancer treated?

Treatment of colon cancer is by multimodality method i.e. Surgery, Chemotherapy and Radiation therapy.

Surgery for colon cancer is the treatment of choice which comprises of resection of the part of affected colon with good margins and resection of all the lymphnodes of the mesentry of the affected segment. After removal of the affected part the proximal cut end is anastomosed to the diastal cut end so that the continuity of the intestines is maintained. Types of surgery are:

  1. Radical Right Hemicolectomy: done for cecum and ascending colon growths.
  2. Radical Extended Right Hemicolectomy: done for ascending and transverse colon growths.
  3. Radical Transverse Colectomy: done for transverse colon growths.
  4. Radical Left Hemicolectomy: done for descending colon and distal transvers colon growths.
  5. Radical Sigmoid colectomy: done for sigmoid colon growth.
  6. Total Colectomy: done for multiple cancers in the colon or for familial diseases.
  7. Colostomy or ileostomy: it can be done to divert the stools temporarily or permanently in advance cases.

Patients receive adjuvant Chemotherapy +/- Radiation Therapy based on the stage of the cancer. In stage IV disease, the cancer may cause problems like blocking the colon causing obstruction and retention of stools in the abdomen or can cause bleeding eventually leading to death so resection of the tumor or atleast a colostomy or ileostomy is required for symptomatic relief.

What are the complications of surgery?

Surgery for colon cancer is a major surgery.Complications include

General complications: lung infections, cardiac complications, deep vein thrombosis and pulmonary embolization, bed sore formation, death due to complications or anesthesia related complications.

Specific complications: anastamotic leak and fecal peritonitis, bleeding, abdominal or wound infections, repeat surgery, intestinal obstruction, vomiting’s, wound related problems and stomal complications like retraction, prolapse etc.

There is always a chance of disease recurrence depending on the stage of the disease.

What will happen if I do not undergo surgery?

If patient does not take treatment there will be cancer progression leading to intestinal obstruction causing abdominal distension and stools in the vomiting, profuse blood loss causing anemia and death, cancer spread to the abdominal cavity causing ascites and abdominal distension and spread to other organs like liver and lung and causing death.

What is the prognosis for a colon cancer patient?

Depending on the factors the cancer treatments may include:

  • Chemotherapy: It is a form of treatment where medicines are used to kill cancer cells.
  • Radiation therapy:It is a form of therapy where radiation is used to kill malignant cells or tissue.
  • Hormone therapy:Hormone therapy or hormonal therapy is the use of hormones in cancer treatments.
  • Surgery:Surgery is the first line of treatment for most people having colon cancer. Its goal is to remove the entire tumour from the colon.

The main types of colon surgery are:

  1. Colon-conserving surgery:The cancer is removed along with the surrounding small amount of normal colon tissue.
  2. Mastectomy:Remove all or part of the colon and possibly nearby structures.
  3. A lumpectomy:Remove the colon lump.

What is Ovarian cancer?

Cancer arising from the ovaries which produces egg cells and female hormones is called as an Ovarian cancer.

How does Ovarian cancer develop?

Ovarian cancer develops due to abnormal growth of 2 different type of cell lines in the ovary. These are: 1) Epithelial Ovarian Cancer – arising from the surface epithelial cells. (Accounts forabout 90% of total primary ovarian tumors.) 2) Non-epithelial ovarian cancer – from other ovarian cells.  There are 2 subgroups; the more malignant germ cell tumors and more benign sex cord stromal tumors.

What causes for Ovarian cancer?

The causes for Ovarian cancer are not well understood. 10% has inherited genetic mutations but 90% are sporadic with few or no risk factors.

  1. Reproductive years: The risk of developing ovarian cancer increase with increase in total no of ovulatory cycles between menarche to menopause. This may be due to repetitive stimulation of germ cells increases the risk of DNA damage thus the risk of cancer.
  2. Age: Epithelial ovarian cancer is more common in age group 60 and older. Recently; there is increased incidencein younger population and epithelial cancers can be seen as early as late 20 and early 30 yrs. Non-epithelial ovarian cancer – Germ cell tumors are diagnosed principally in the first two decades of life, and sex cord-stromal tumors are more common in adult women (granulosa Ovarian cancer:diagnosis of 50 years, but 90% of juvenile type occurs in pre-pubertal girls and Sertoli cell tumors in
  3. Family history: it is an important risk factor of developing ovary, breast and few other cancers. Mutations like BRCA1 and BRCA2increases the risk of multiple cancers.
  4. Personal or family history of ovarian, breast, endometrial or colon cancer is also associated with a higher risk of developing ovarian cancer.
  5. Obstetrics history and Breast feeding: Women with no children have increased risk as they have more exposure to no of ovarian cycles.The risk decreases with each live birth. During pregnancy and lactation;ovulation is temporally halted so there is reduction in the total number of ovulatory cycles.
  6. Race: Caucasian women have a 30 to 40% higher risk of developing ovarian cancer than black or Hispanic women.
  7. Combined oral contraceptives pills: (OCPs) suppress ovulation and therefore exert a protective effect against cancer. Long-term use of OCP’s not only reduces the risk up to 50% and also has long term effect of preventing cancer.
  8. Gynaecological surgery. Both tubal ligationand hysterectomy are associated with a reduction in the risk of developing ovarian cancer. The surgical removal of the ovaries significantly reduces the risk of developing ovarian cancer.
  9. Hormone replacement therapy: HRT with oestrogens in postmenopausal women, if given for periods longer than 10 years, may be associated with a higher risk for ovarian cancer.

What are the symptoms of Ovarian Cancer?

Early Ovarian cancers are more commonly asymptomatic and may be suspected during a routine physical check-up or routine investigations.When disease is advanced, the following symptoms may be present but they are not specific for ovarian cancers.

  1. Pelvic or abdominal discomfort or pain.
  2. Abdominal fullness (due to fluid accumulation also called ascites) or abdominal swelling (mass in the pelvis and/or abdomen).
  3. Early satiety (feeling of full stomach even with less food intake), dyspepsia (stomach upset),Nausea (feeling sick) and anorexia (loss of appetite).
  4. Change in Bowel habit (due to bowel obstruction)like constipation or loose stools with mucous.
  5. Increased frequency of urination.
  6. Pain during sexual intercourse.
  7. Shortness of breath due to fluid accumulating in the chest around the lungs (called pleural effusion) .
  8. This are all the signs of advanced disease

What are the symptoms of Ovarian Cancer?

Early Ovarian cancers are more commonly asymptomatic and may be suspected during a routine physical check-up or routine investigations.When disease is advanced, the following symptoms may be present but they are not specific for ovarian cancers.

  1. Pelvic or abdominal discomfort or pain.
  2. Abdominal fullness (due to fluid accumulation also called ascites) or abdominal swelling (mass in the pelvis and/or abdomen).
  3. Early satiety (feeling of full stomach even with less food intake), dyspepsia (stomach upset),Nausea (feeling sick) and anorexia (loss of appetite).
  4. Change in Bowel habit (due to bowel obstruction)like constipation or loose stools with mucous.
  5. Increased frequency of urination.
  6. Pain during sexual intercourse.
  7. Shortness of breath due to fluid accumulating in the chest around the lungs (called pleural effusion) .
  8. This are all the signs of advanced disease Functional tumours: Sex cord stromal tumours produce different type of hormones causing symptoms. Young prepubescent girls who have ovarian tumours may have dysgenetic gonads due to variation in the chromosomes. These patients require special  blood tests to identify number and size of the chromosomes (karyotyping).
  9. Production of estradiol inprepubertal girls may cause sexual precocity (premature onset of puberty) or irregular menses. In postmenopausal woman it may cause uterine bleeding.
  10. Excess production of testosterone (a male hormone) may cause virilization.
  11. Excess production of cortisol may cause weight gain, thinning of the skin and excess hair growth (Cushing syndrome).

What are the tests required to evaluate Ovarian cancer?

  1. A through General examination (breast and other systems) and pelvic examination (Per Abdomen, Per Speculum, Per Vaginal examination).
  2. Ultrasound (Trans vaginal/ Abdominal):Trans Vaginal ultrasound examination is done with the probe inserted vaginally and Abdominal USG by placing the probe on the abdomen. It helps in detecting the presence of a tumour, organ of origin, probablybenign or suspicious of malignanancy ( based on solid component, walls of the lesion, irregular margins and the presence of many blood vessels and lymphnodes),  ascites (accumulation of fluid in the abdominal cavity) or abdominal spread.
  3. Magnetic Resonance Imaging (MRI): MRI pelvis* is done to differentiate the type of mass; benign or malignant especially if USG is doubtful.
  4. Contrast Enhanced Computerized Tomography (CECT) Thorax + Abdomen + Pelvis: its helps in staging of disease and treatment planning.
  5. Positron-emission tomography with computed tomography (PET-CT): this imaging visualizes the anatomy and metabolic activity of cells. It is not recommended for primary cancer detection but can be done in recurrent cancers and some specific tumor types.
  6. Tumour markers: Cancer Antigen 125 (CA125): It helps in diagnosis, monitoring response to treatmentand/or to find out tumor recurrence. Elevated CA125 are not only seen in epithelial ovarian cancers but also in various non- cancerous conditions like menstruation, endometriosis, adenomyosis, pelvic inflammatory disease, cysts, uterine fibroids,, and others. Therefore a combination of USG with CA125 level is more accurate for the diagnosis of primary ovarian cancer. Non-epithelial ovarian cancers are rare and are difficult to diagnose. Tumour markersmay help in reaching the diagnosis. Germ cell tumors usually have human chorionic gonadotropin (hCG), α-fetoprotein (AFP) and lactate dehydrogenase (LDH). Other hormones like androgen (virilization), Estradiol( Pre cautious puberty) and cortisol (Cushing syndrome), Inhibin are elevated in granulosa cell tumours* (estradiol and Inhibin) and Sertoli*-Leydig* cell tumours (testosterone). Neuron-specific enolase (NSE) is a marker in some ovarian neuro-endocrinetumours.
  7. Histopathological examination: biopsy (taking a piece) from the tumor is the confirmatory test for any cancer but it is not done in early ovarian cancers where the tumor is confined to the ovary as it upstages the disease and this patient may require un necessary chemotherapy. In advanced cases a biopsy can be taken from pelvic or peritoneal mets or the ascites can be collected to see the malignant cells.
  8. Benign tumours may grow larger, but do not spread to other parts of the body. – Malignant* tumours are composed of cancer cells. Malignant tumours grow in an unlimited manner, and may invade and destroy the surrounding tissue. They may also spread to other parts of the body (metastases*). – Borderline tumours* are composed of cells that are neither considered benign*, nor malignant*, but rather show a low malignant potential. These lesions are also known as tumours of intermediate malignancy*, tumours of low malignant potential, and atypical proliferative tumours. Borderline tumours are usually serous carcinomas, less frequently mucinous carcinomas and rarely endometrioid carcinomas.

How is Ovarian cancer treated?

Early stage or few advanced Ovarian cancer (were R0 or complete resection can be achieved)are treated with Oopherectomy + Frozen section confirmation +/- Staging Laparotomy/Laproscopywith or without Adjuvant chemotherapy.

In late advance stages where patient has diffuse peritoneal, liver metastasis or locally advanced disease or positive plural effusion ( R0 not possible); patient receives 3 cycles of Neo Adjuvant Chemotherapy (3-4 cycles) followed by Staging procedure and then completion chemotherapy.

What are Frozen Section and Staging Laparotomy?

Frozen Section or Cryosection: It is procedure for to perform rapid microscopic analysis of a specimen. The specimen is cryofreezed and slides are seen immediately to confirm the presence of cancer. It does not have 100% accuracy but it is fairly reliable. It is possible that the frozen report may say the specimen is cancer and the final report can be non-cancer and vice versa. Surgical Staging: Laparotomy/ Laparoscopy : A lower midline abdominal incision is made and whole of the abdominal cavity and organs are explored. Ascites or peritoneal washing should be collected for malignant cells and peritoneal biopsies are to be taken. The involved ovary is removed without ruptuting it so not to upstage the disease. The other ovary and the uterus is also removed. Pelvic and para aortic lymphnodes are removed. Omentum and any other involved organ is removed. This is called R0 resection when no or only <1cm tissue is left behind in the abdomen for the chemotherapy to take care of it.

In ovarian cancer, staging is complete when the following examinations are performed: clinical examination, radiological investigations, a surgical exploration of the abdomen (called surgical staging), and the histopathological examination of tissue from the primary tumour and from biopsies from possibly affected other organs.

What will happen if i donot undergo surgery? What are the complications of surgery? What is the prognosis for a breast cancer patient?

Low-grade and high-grade serous carcinomas, Endometrioid carcinomas, Clear-cell carcinomas, Mucinous carcinomas consist of two subgroups – The intestinal-type mucinous tumour is the most common. The endocervical-type (seromucinous or Mullerian) mucinous tumour is usually a borderline tumour*, and is similar to the borderline serous tumours, Transitional cell carcinomas, Squamous carcinomas, Undifferentiated carcinomas. Germ cell tumours arise from the egg cells within the ovary. Overall, germ cell tumours constitute only 5% of all ovarian tumours, but they make up more than 75% of all the malignant* ovarian tumours that are diagnosed in pre-adolescent girls. The so-called dermoid* cyst*(or mature cystic teratoma*) is a subtype of germ cell tumours that may account for 20% of all ovarian tumours, and is usually benign*. – Sex cord stromal tumours arise from the ovarian stroma (the soft tissue that forms the supportive structure of the ovary) or from the sex cords (the structures that during development of the reproductive organs give rise to specific cell types such as Leydig cells*, Sertoli cells*, granulosa cells* and thecal cells*). Sex cord stromal tumours make up 5% of all ovarian tumours and 7% of all ovarian malignant* tumours. They occur mostly in women of adult age. These tumours usually produce hormonal substances, producing distinct clinical symptoms such as virilization*, or endometrial hyperplasia* which may cause irregular menses or postmenopausal bleeding. Several types of sex cord stromal tumours are recognized. The most common type of malignant* tumour in the group of sex cord stromal tumours is the granulosa cell tumour*. These tumours can occur in adults but are most frequent in juveniles, namely in females younger than 20 years of age. In this age group they often present with signs of sexual precocity (premature onset of puberty). Immunohistochemistry* may help in the differentiating these tumours from other types of ovarian cancer since these tumours typically show tissue expression of the proteins* CD99* and melanA* (in the adult form) and α-inhibin* and calretinin* (in the adult and juvenile forms). The Sertoli cell*, Leydig cell* and Sertoli-Leydig cell tumours form a subtype of sex cord stromal tumours that may typically produce male hormones. The Leydig cell tumour (also called hilus cell tumour) is always benign* and typically presents virilization* due to secretion of androgen*. The Sertoli-Leydig cell tumour also presents itself in younger patients and may also produce hormones. Also in these tumours, immunohistochemistry* may help in their identification since they typically show expression of the specific proteins* α-inhibin and low molecular weight cytokeratin. – Carcinosarcomas* make up 2 to 4% of all ovarian tumours. Typically these tumours consist of malignant* cells arising from the ovarian epithelium* as well as from the ovarian stroma. – Small cell and neuro-endocrine* tumours of the ovary characteristically consist of cells that are smaller than normal cells. Neuro-endocrine tumours of the ovary consist of cells that typically occur in endocrine and nervous systems*. This category of tumours, which also consists of different subtypes, makes up approximately 1% of all ovarian cancers and each subtype has a characteristic clinical presentation. These tumours are rare but most of them are very aggressive, in particular when they are diagnosed beyond FIGO stage I. Squamous cell carcinoma arising within a dermoid* cyst*/teratoma* is a malignant* tumour that arises within a dermoid cyst: this so-called ‘malignant transformation’ is uncommon and occurs in only 1 to 2% of dermoid cysts. These tumours typically occur in postmenopausal women and are usually diagnosed in a late stage when the large tumour size causes discomfort or when twisting of the tumour (called torsion) causes pain. The diagnosis is also often made when a patient undergoes surgery for a presumed dermoid cyst. – Struma ovariimalignum (or strumal carcinoid) is a malignant* tumour that arises within a teratoma* and that consists of more than 50% of tissue that is typically found in the thyroid gland*. Struma ovariimalignum is very uncommon and is usually diagnosed as an incidental finding in 50- to 60-year old women. It rarely produces metastases*. Very rarely, the ovarian tumour represents a metastasis from a primary thyroid malignant tumour, and this possibility should therefore be investigated in patients presenting strumal carcinoid. · Grade The so-called grade of a malignant* tumour reflects the presence of atypical characteristics of the cells and/or the atypical architecture of the tumour. The grade is considered to provide information on the rate at which the tumour will grow and the degree to which it will be invasive*. For ovarian cancer, numerous grading systems can be used. The grading system may differ according to the histological type* of the tumour. A number (usually from 1 to 3) or an adjective (low or high) is attributed to the grade. A general rule is that the lower the grade is, the better the prognosis*

What are the treatment options?

The planning of the treatment for the patient involves a multidisciplinary team* of medical professionals. The treatment will usually combine surgery, and systemic chemotherapy*, which acts on the cancer cells wherever they are located in the body.

STANDARD TREATMENT PLAN FOR OVARIAN CANCER Treatment plan for early disease (FIGO stage I and IIA) At these stages, the tumour is confined to the ovaries (stage I) or to the ovaries, the uterus and/or the Fallopian tubes (stage IIA). Since there is no extension beyond the pelvis*, the main goal of the treatment is to surgically remove the tumour as well as the organs to which the tumour has spread, if that were the case.

total abdominal hysterectomy* (resection of the uterus) · bilateral salpingo-oophorectomy* (resection of the ovaries and Fallopian tubes on both sides) ·omentectomy (resection of a large fold of the tissue that lines the bowel) In addition, as part of the staging procedure, the entire abdominal cavity is evaluated and includes · assessment of the pelvic and para-aortic* retroperitoneum (the space behind the tissue that lines the abdominal cavity in the region of the pelvis* and the aorta) · biopsy* sampling of the peritoneum* (the tissue that lines the abdominal cavity) · peritoneal* washing* (salt-water is used to wash the abdominal cavity and then examined for the presence of malignant* cells)

In selected patients, so-called fertility-sparing surgery can be performed. This means that one ovary and Fallopian tube, as well as the uterus, are preserved.

In patients with stage I ovarian cancer, grade is the strongest indicator for the risk of recurrence*. § Low risk: stage IA and IB, grade 1 § Medium risk: stage IA and IB, grade 2 § High risk: stage IA grade 3, stage IC all grade 1, 2 or 3; stage IB grade 2 or 3, and clear cell histology Other clinical factors that determine the risk of recurrence are: § the occurrence of tumour rupture before surgery or during surgery § the presence of a tumour on both ovaries § age at time when tumour presents itself. Therefore for those patients in whom surgical staging and histopathological examination of the tumour tissue indicate the presence of intermediate-risk or high-risk early disease, it is recommended to give 6 cycles of chemotherapy* with carboplatin*, given intravenously*. Adjuvant* chemotherapy may reduce the risk of recurrence and/or progression. Treatment plan for advanced disease (FIGO stages IIB to IIIC) At these stages, the tumour has extended into pelvic tissues other than the uterus and Fallopian tubes; the tumour has extended into upper abdominal tissues and/or has caused distant metastasis*. The tumour has spread significantly and it is difficult or impossible to surgically remove all tumour growth. Therefore, the goal of the initial treatment for these patients is to maximally remove tumour tissue through surgery, and to subsequently target remaining tumour cells using chemotherapy*. Chemotherapy is given through a vein and therefore acts systemically on the tumour cells. More and more, part of the chemotherapy is administered before surgery to reduce the extent of the tumour, thus allowing maximal removal of the tumour during surgery. Debulking surgery* As for all patients suspected of ovarian cancer, a laparotomy* is performed for comprehensive surgical staging (see chapter on ‘Staging’). If surgical staging shows and/or confirms advanced disease, the initial surgical intervention aims to remove the bulk of the tumour, meaning that the surgeon will try to surgically remove all visible tumour. This procedure is also referred to as maximal (or optimal) cytoreduction. The extent of the surgical interventions in this procedure, and the likelihood that the surgeon can achieve optimal cytoreduction, depends on the stage of the individual patient. The goal of this procedure is to remove as much as possible of the primary tumour mass, and the term optimal cytoreduction refers to the absence of residual disease (no tumour left). Standard elements of the procedure are a total abdominal hysterectomy*, bilateral salpingooophorectomy*, omentectomy, lymphadenectomy and peritoneal* washing*; the procedure may further include (partial) resections of the peritoneum*, liver, spleen, stomach, gallbladder, pancreas, bowel and urinary bladder. If optimal cytoreduction is not possible, and the patient subsequently either responds or shows stable disease under chemotherapy*, so-called ‘interval debulking* surgery’ should be considered. This means that after three cycles of chemotherapy, patients undergo debulking surgery, which is followed by another three cycles of chemotherapy. This strategy is becoming more widely accepted and more frequently offered to patients, especially when there is extensive tumour dissemination. Chemotherapy* After primary surgical tumour reduction, the standard treatment for patients with advanced ovarian cancer is platinum-based therapy*, in particular a combination of carboplatin* and paclitaxel*, given intravenously* in six cycles. Some patients with extensive tumour dissemination may receive 3 cycles before surgery in order to decrease the extent of the tumour, then undergo surgery and afterwards receive the remaining 3 chemotherapy cycles. For patients who develop an allergy to or do not tolerate paclitaxel, the combination of docetaxel and carboplatin or of pegylated liposomal doxorubicin* and carboplatin can be considered an alternative. In the USA, it has been suggested that intraperitoneal chemotherapy – the administration of chemotherapy through a surgically implanted flexible tube that allows passage of fluids into the abdomen – should be offered to patients with very limited or no residual disease after surgery. However, a combination of intraperitoneal and intravenous* chemotherapy cannot be considered as standard of care in Europe. Targeted therapy* Bevacizumab* is an antibody* that binds to vascular endothelial growth factor* (VEGF), a growth factor for blood vessels. Ovarian cancer cells produce high amounts of VEGF, which stimulates the formation of new blood vessels in and around the tumour. Blocking VEGF using bevacizumab therefore may prevent this from occurring. Ovarian cancer: a guide for patients – Information based on ESMO Clinical Practice Guidelines – v.2014.1 Page 22 This document is provided by the Anticancer Fund with the permission of ESMO. The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified, reproduced or disseminated in any way without written permission from ESMO and Reliable Cancer Therapies. Adding bevacizumab to chemotherapy could be recommended as initial treatment to patients with either stage III cancer and residual tumour of more than 1 cm after debulking* surgery, or stage IV cancer. It should be given with paclitaxel and carboplatin and for one year. Treatment plan for metastatic* disease (FIGO stage IV) Approximately 15% of patients with ovarian cancer are diagnosed at stage IV (metastatic) disease. As explained in the section of treatment of advanced disease, the treatment outcome at this stage depends also on residual disease after surgery of primary tumour mass, which is followed by chemotherapy* consisting of six cycles of platinum-paclitaxel*. For patients who develop an allergy to or do not tolerate paclitaxel, the combination of docetaxel and carboplatin or of pegylated liposomal doxorubicin* and carboplatin can be considered alternatives. A drug called bevacizumab* could be added to chemotherapy as described in the previous section on advanced disease

What happens after the treatment?

It is not unusual for cancer patients to experience treatmentrelated symptoms after the treatment has been completed. · Patients may experience anxiety, sleeping difficulty or depression, and may need psychological support. · During and after treatment, nutrition may become problematic due to reduced appetite, nausea and general malaise · Difficulties with concentration and memory are not uncommon side effects of intravenous* chemotherapy*. Follow-up with doctors After completion of treatment the doctor will propose a follow-up that aims to: · detect and prevent adverse effects of the treatment · detect possible recurrence* and direct appropriate treatment · provide medical information, psychological support and referral to specialized support providers to optimize returning to normal daily life. Because of the heterogeneity of the different types of ovarian cancer, there is not one single and generally accepted follow-up protocol for patients. The follow-up protocol for epithelial ovarian cancer includes taking a history of the patients general physical health and symptoms related to disease and physical examination including bimanual pelvic examination* every 3 months for 2 years, every 4 months during the third year and every 6 months during years 4 and 5. Measurement of CA125 is useful in follow-up of responders after completion of chemotherapy*, since it has been shown to be predictive of ovarian cancer recurrence. Progression or recurrence* of disease based on serum CA125 is defined on the basis of progressive serial elevation of serum CA125. Elevated values must be confirmed by two separate measurements obtained at least 1 week apart. If CA125 rises, chemotherapy can be delayed until signs or symptoms of tumour recurrence present themselves. However, it is important to note that potentially resectable recurrence can be signalled by a CA125 rise, therefore informed choices should be offered. CT* scan should be performed if there is clinical or CA125 evidence for progressive disease. PET*-CT seems to be superior to CT in detecting more tumour sites, especially in lymph nodes, peritoneal* and subcapsular* liver disease. Specificities in follow-up of patients with non-epithelial ovarian cancer Typically, follow-up is the same as for epithelial ovarian carcinoma, although in some cases it may vary. Follow-up visits must include taking a history of the patients general physical health and symptoms related to disease, physical examination with pelvic examination* and tumour markers every 3 months for the first 2 years, then every 6 months during the third, fourth and fifth year. A pelvic ultrasound* should be carried out every 6 months in those patients who have undergone fertility-sparing surgery, whereas a CT-scan* of the abdomen and pelvis is usually carried out according to clinical indication. Approximately 75% of germ cell tumour recurrences occur within the first year after initial treatment. Conversely, the indolent nature of sex cord stromal tumours with the tendency for late recurrence (the median time to recurrence is approximately 4 to 6 years) Ovarian cancer: a guide for patients – Information based on ESMO Clinical Practice Guidelines – v.2014.1 Page 29 This document is provided by the Anticancer Fund with the permission of ESMO. The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified, reproduced or disseminated in any way without written permission from ESMO and Reliable Cancer Therapies. requires long-term follow-up. Several reports describe recurrences occurring >20 years (up to 37 years) after diagnosis. Many granulosa cell tumours* are slow-growing tumours, and could recur after many years, often up to 20 years after diagnosis. Measurement of estradiol*, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and inhibin* is used, but they are most reliable in postmenopausal patients and in patients in whom both ovaries have been removed. In patients with ovarian neuro-endocrine* tumours, a scan with octreotide (octreoscan) is performed postoperatively to detect tumour cells that might be persisting elsewhere in the body (see also paragraph ‘How is ovarian cancer diagnosed’). A radio-actively labelled drug called octreotide is administered intravenously*; the drug attaches to the neuro-endocrine* tumour cells in the patient’s body, and this technique thus allows for testing and specifically visualizing neuro-endocrine tumour cells anywhere in the body. Standard work-up also includes GUT hormone analysis*. In patients treated for a germ cell tumour, measurement of hCG*, AFP* and LDH* may help in detecting recurrence* of the disease. MRI* has been used more often than CT to avoid radiation in this usually young group of patients. In patients with strumaovariimalignum, clinical examination and thyroid hormone replacement* in doses that fully suppress thyroid-stimulating hormone (TSH) is needed. Serial measurement of thyroglobulin* (Tg) level has replaced whole body radio-iodine* scintigraphy. Follow-up is lifelong, principally to monitor thyroid function and Tg. The recommended follow-up for patients treated for squamous cell carcinoma arising within dermoid* cysts* is 5 years,

What if the cancer comes back?

When the cancer returns, it is called ‘recurrence*’. The treatment decision will depend on the type of ovarian cancer, the timing and the nature of the recurrence, the extent to which the patient received and responded to prior chemotherapy*, and the general health status of the patient. Surgical resection of the recurring tumour. This may be considered in patients that have responded well to previous chemotherapy treatment, particularly those who develop an isolated recurrence long after the treatment has finished, and otherwise have a good general health status. Surgical intervention may be needed to relieve symptoms from, for example, bowel obstruction caused by the tumour. ·


Chemotherapy The choice of the type of chemotherapy depends on the time between the last dose of the platinumbased chemotherapy administered the first time and the time of disease recurrence. The four categories 1) platinum-refractory when the tumour progresses during chemotherapy or within 4 weeks after the last dose, and 2) platinum-resistant when a recurrence develops less than 6 months after the last dose. The treatment plan is providing individualised supportive care, which should aim to maintain and/or improve quality of life and control symptoms. Drugs that can be used are paclitaxel, topotecan, pegylated liposomal doxorubicin* and gemcitabine. As no treatment has proven to be superior to another, 3) partially platinum-sensitive when a recurrence develops between 6 and 12 months after the last dose and platinum-sensitive when a recurrence develops more than 12 months after the last dose. These patients have a high probability of responding again to platinumcontaining* chemotherapy with pegylated liposomal doxorubicin* 3) platinum sensitive rec


There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue* is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.

  1. DebulkingsurgerySurgical removal of as much of a tumor as possible. Debulking may increase the chance that chemotherapy or radiation therapy will kill all the tumor cells. It may also be done to relieve symptoms or help the patient live longer. Also called tumor debulking.
  2. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.
  3. Omentum A fold of the peritoneum* (the thin tissue that lines the abdomen) that surrounds the stomach and other organs in the abdomen.
  4. Interval debulking surgery

If your surgeon thinks it is possible to remove all or most of your cancer, you will have surgery before your chemotherapy. But if it would be difficult for the surgeon to remove enough of the cancer, you may have chemotherapy first. In this case, you have a biopsy of the tumour first to confirm the diagnosis, followed by chemotherapy and then surgery. This is called neo adjuvant chemotherapy (this is pronounced nee-oh-ad-joo-vent) or primary chemotherapy.

This operation is called interval debulking surgery (IDS).

You may also have IDS if you have already had surgery as your first treatment. You have this done if your surgeon couldn’t remove enough of the cancer during your first operation or if it was done by a non specialist surgeon. So in this case, you have surgery first. Then you have some chemotherapy, followed by the second operation to remove the rest of the cancer, followed by more chemotherapy.

What is thyroid cancer?

It is a cancer that starts in the thyroid gland. It commonly spreads to neck lymph nodes, bones, liver and lung. It’s prognosis is considered to be one of the best among all the cancers affecting human body.

What is thyroid and what is its function?

The thyroid gland is a butterfly shaped organ just below the Adam’s apple in the front part of the neck. It has two lobes — right and left which are joined by a structure called the isthmus it has 2 separate functions controlled by two types of cells. The Follicular cells use iodine from the blood to make thyroid hormone, which controls body metabolism and C cells (also called parafollicular cells) make calcitonin, a hormone that helps control how the body uses calcium.

What are the types of thyroid cancers?

There are several types of thyroid cancer. Differentiated thyroid cancers Most thyroid cancers are differentiated cancers. These cancers start in thyroid follicular cells. In these cancers, the cells look a lot like normal thyroid tissue when seen under a microscope. Papillary thyroid cancer: About 8 of 10 thyroid cancers are papillary cancers. Most often they grow very slowly. Often they grow in only one lobe of the thyroid gland. Even though they grow slowly, they often spread to the lymph nodes in the neck. But most of the time, these cancers can be cured and are rarely fatal. Follicular thyroid cancer: This is the next most common type of thyroid cancer. It is much less common than papillary thyroid cancer, making up about 1 out of 10 thyroid cancers. Follicular cancers usually stay in the thyroid gland. They usually don’t spread to lymph nodes, but some can spread to other parts of the body, such as the lungs or bones. The outlook for follicular cancer may not be quite as good as that of papillary cancer, but it is still very good in most cases. Hürthle cell cancer is a kind of follicular cancer. It accounts for a very small number of thyroid cancers. The outlook may not be as good as that of typical follicular cancer because this type is harder to find and treat. Rarer types of thyroid cancers These cancers occur less often than differentiated thyroid cancers. Medullary thyroid cancer (MTC): This accounts for about 4% of thyroid cancers. It starts in the C cells of the thyroid gland. In some cases MTC can run in families. Sometimes these cancers can spread to other parts of the body even before a lump is found in the thyroid. The outlook for these cancers is not quite as good as that for differentiated thyroid cancers. Anaplastic thyroid cancer: This is a rare type of thyroid cancer, making up about 2% of all thyroid cancers. This cancer is also called undifferentiated because the cancer cells do not look very much like normal thyroid cells under the microscope. It is a fast-growing cancer that often spreads quickly into the neck and to other parts of the body and is very hard to treat. There are also other types of thyroid cancers that occur even more rarely. To learn more about rare types of thyroid cancers, see our more detailed document Thyroid Cancer. The rest of this document only covers differentiated thyroid cancer. What are the risk factors for thyroid cancer? While the exact cause of most thyroid cancers is not known, several risk factors have been linked to the disease. A risk factor is anything that affects a person’s chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed. But risk factors don’t tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may have few or no known risk factors. Even if a person with thyroid cancer has a risk factor, it is very hard to know what part that risk factor might have played in the cancer. Some of the risk factors that make a person more likely to develop thyroid cancer include: • Gender – thyroid cancers are more common in women. • Age – women are most likely to get it in their 40s or 50s, while men are more likely to get it in their 60s or 70s • A diet low in iodine (this is rare in the United States) • Radiation exposure – the risk is highest if exposure occurs in childhood • Family history – having a parent, brother, sister, or child with thyroid cancer increases your risk of thyroid cancer. • Certain genetic conditions To learn more about these risk factors, please see Thyroid Cancer. Can thyroid cancer be prevented? Most people with thyroid cancer have no known risk factors that they can change, so there is no sure way to prevent most cases of this disease. Radiation exposure, especially in childhood, is a known risk factor for thyroid cancer. Because of this, doctors no longer use radiation treatment for minor diseases. Imaging tests such as x-rays and CT scans also expose children to radiation, but at much lower doses. If there is an increased risk of thyroid cancer from these tests is likely to be small, but to be safe, children should not have these tests unless they are clearly needed.. Signs and symptoms of thyroid cancer Thyroid cancer can cause any of these signs or symptoms: • A lump in the neck, sometimes growing quickly • Swelling in the neck • Pain in the front of the neck, sometimes going up to the ears • Hoarseness or other voice changes that do not go away • Trouble swallowing • Trouble breathing • A constant cough that is not due to a cold • A tumor in the thyroid seen on an imaging test If you have any of these signs or symptoms, talk to your doctor right away. Many of these symptoms can be caused by other things. Thyroid lumps (nodules) are common and are usually benign. Still, if you have any of these problems, see your doctor right away so the cause can be found and treated, if needed. How is thyroid cancer found? Many thyroid cancers can be found early. Some early thyroid cancers are found when patients see their doctors because of neck lumps or bumps they have noticed. If you have symptoms such as a lump or swelling in your neck, you should see your doctor right away. Many thyroid cancers are found by the doctor during a routine checkup or when people have imaging tests (such as ultrasound or CT scans of the neck) for other health problems. If you have any signs or symptoms that suggest you might have thyroid cancer, your doctor will take your history, examine you, and then order more tests. Medical history and physical exam Your doctor will take a medical history. You will be asked questions about your possible risk factors, symptoms, and any other health problems or concerns. If someone in your family has had thyroid cancer, tell your doctor, as you might be at high risk for this disease. During the physical exam, your doctor will pay special attention to the size and firmness of your thyroid and any enlarged lymph nodes in your neck. Imaging tests to look at the thyroid If you have a lump in your thyroid, your doctor may order one or more of these tests Ultrasound Ultrasound uses sound waves to create pictures of parts of your body. For this test, a small wand is placed on the skin in front of your thyroid gland. It gives off sound waves and picks up the echoes as they bounce off the thyroid. The echoes are seen as a black and white image on a computer screen. No radiation is used in this test. This test can help show if thyroid nodules are solid or filled with fluid. (Solid ones are more likely to be cancer.) It can also be used to help guide a biopsy needle into a nodule to take a sample. Ultrasound can also help show whether any nearby lymph nodes are enlarged because the thyroid cancer has spread. Radioiodine scan Radioiodine scans can be used to help find out if someone with a lump in the neck might have thyroid cancer. They are also often used in patients with differentiated thyroid cancer to help show if it has spread. (Medullary thyroid cancer cells do not take up iodine, so radioiodine scans are not used for this cancer.) For this test, a small amount of radioactive iodine is swallowed as a pill or put into a vein. Over time, the iodine is absorbed by the thyroid cells. A special camera is used several hours later to see the radioactivity. For a thyroid scan, the camera is placed in front of your neck to measure the amount of radiation in the gland. Abnormal areas of the thyroid that have less radioactivity than the surrounding tissue are called cold nodules, and areas that take up more radiation are called hot nodules. Hot nodules usually are not cancer, but cold nodules can be either benign or cancer. So this test by itself can’t diagnose thyroid cancer. After surgery for thyroid cancer, whole-body radioiodine scans are useful in looking to see if cancer has spread throughout the body. Radioactive iodine can also be used to treat differentiated thyroid cancer, but it is given in much higher doses. This type of treatment is described in the section “Radioactive iodine treatment.” Biopsy If imaging tests such as ultrasound and a radioiodine scan suggest that you could have thyroid cancer, you will need a biopsy to know for certain. For a biopsy, a sample of cells from the area of concern are removed and looked at under a microscope. The most common type of biopsy to look for thyroid cancer is called a fine needle aspiration (FNA) biopsy. For this, the doctor puts a thin, hollow needle into the lump to draw out cells and a few drops of fluid. This type of biopsy can usually be done in your doctor’s office or clinic. Before the biopsy, medicine may be used to numb the skin over the nodule. Sometimes ultrasound is used to help the doctor find the right place to put the needle. Sometimes an FNA biopsy will need to be repeated because the samples didn’t contain enough cells. Most FNA biopsies will show that the thyroid nodule is benign. Only about 1 out of every 20 biopsies will clearly show cancer. Sometimes the doctor can’t tell for certain that the cells are cancer just by how they look under the microscope and will need to do special tests to look for certain genes. In some cases, another biopsy may be needed to get a better sample. This might include a biopsy using a larger needle or a surgical “open” biopsy to remove the nodule or a larger part of the thyroid gland. This kind of biopsy is done in the hospital while you are in a deep sleep. Imaging tests to look for spread of thyroid cancer Imaging tests make pictures of the inside of your body. They may be done for a number of reasons: • To find suspicious areas that might be cancer • To learn how far cancer may have spread • To help find out if treatment has been working Chest x-ray If you have thyroid cancer, your chest may be x-rayed to see if cancer has spread to your lungs. Computed tomography (CT) scan The CT scan is an x-ray test that gives detailed pictures of your body. The CT scan can help show the place and size of thyroid cancers and whether they have spread to nearby areas. A CT scan can also be used to look for spread into distant organs like the lungs. A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures. Before the test, you may be asked to drink a contrast solution or receive an IV (intravenous) line through which a different contrast dye is put in. This helps better outline structures in your body. You might feel some flushing (a feeling of warmth). Some people are allergic and get hives. Rarely, more serious problems like trouble breathing or low blood pressure can happen. Be sure to tell the doctor if you have any allergies or have ever had any problems from contrast dye used for x-rays. In some cases, a CT scan can be used to guide a biopsy needle right into a suspected area of cancer spread. Because the CT contrast dye contains iodine, (which can cause problems with radioiodine scans described above), many doctors prefer MRI scans instead of CT scans. Magnetic resonance imaging (MRI) scan Like CT scans, MRI scans can be used to look for cancer in the thyroid or cancer that has spread to other parts of the body. But ultrasound is usually the first choice for looking at the thyroid. MRI scans are helpful in looking at the brain and spinal cord. MRI scans use radio waves and strong magnets instead of x-rays. A contrast material is often put into a vein before the scan to better show the details. MRI scans take longer than CT scans — often up to an hour. And you might have to lie inside a narrow tube, which can upset people who don’t like enclosed spaces. Newer, more open MRI machines can sometimes be used instead. The machine also makes buzzing and clicking noises, so some centers provide earplugs to block it out. PET (positron emission tomography) scan For a PET scan, a kind of radioactive sugar is put into the blood. The amount used is very low. Because cancer cells in the body are growing quickly, they absorb more of the sugar than normal cells. After waiting about an hour, you lie on a table in the PET scanner for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. This test can be very useful if your thyroid cancer is one that doesn’t take up radioactive iodine. In this case, the PET scan may be able to tell whether the cancer has spread. Some machines are able to do both a PET and CT scan at the same time. This lets the doctor see areas that “light up” on the PET scan in more detail. Blood tests Blood tests alone can’t tell if a person has thyroid cancer. But they can help show if the thyroid is working as it should, which may help the doctor decide what other tests may be needed. Thyroid tests Your blood may be tested for levels of thyroid hormones (T3 and T4), thyroidstimulating hormone (TSH), and thyroglobulin to see if the thyroid is working normally. These tests can’t tell if you have thyroid cancer, but they may be done during and after cancer treatment to check thyroid function or to help find out if the cancer may have returned. Other blood tests You may have other blood tests as well. If you are scheduled for surgery, tests will be done to check your blood cell counts, to look for bleeding problems, and to check your liver and kidney function. Vocal cord exam Thyroid tumors can sometimes affect the vocal cords. If you are going to have surgery to treat thyroid cancer, a vocal cord exam probably will be done ahead of time to see if the vocal cords are moving the way they should. For this exam, the doctor looks down the throat at the voice box with special mirrors or with a thin tube with a light and a lens on the end (a laryngoscope). Staging of thyroid cancer Staging is the process of finding out if and how far a cancer has spread. The stage of a cancer is important in choosing the best treatment. The stage can also help predict the patient’s outlook (prognosis) and chance for a cure. Staging is based on the results of the physical exam, biopsy, and imaging tests (ultrasound, radioiodine scan, CT scan, MRI, chest x-ray, and/or PET scan), which are described in the section “How is thyroid cancer found?” The most common system used to describe the stages of thyroid cancer is the American Joint Committee on Cancer (AJCC) TNM system. The stages of thyroid cancer are usually labeled using Roman numerals I through IV (1-4). For most cancers, the lower the number, the less the cancer has spread. Unlike most other cancers, though, thyroid cancer staging also takes into account the patient’s age. This means that a thyroid cancer can have a different stage depending on the age of the patient. More information about the staging of thyroid cancer can be found in our more detailed document Thyroid Cancer. Recurrent cancer Cancer that comes back after treatment is called recurrent (or relapsed). If thyroid cancer returns it is usually in the neck, but it might come back in a different part of the body (for instance, lymph nodes, lungs, or bones). The stage assigned stays the same even if the disease recurs. If you have any questions about the stage of your cancer or how it affects your treatment options, be sure to ask your doctor. Survival rates for thyroid cancer Some people with cancer may want to know the survival rates for their type of cancer. Others may not find the numbers helpful, or may even not want to know them. Whether or not you want to read about survival rates is up to you. If you do not want to read about the survival rates for thyroid cancer, skip to the next section. The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Of course, many people live much longer than 5 years (and many are cured). Five-year relative survival rates compare the 5-year survival rate to what would be expected for people without cancer. This helps take into account deaths from causes other than cancer. This is a better way to see the impact that cancer can have on survival. To get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improved treatments may result in a better outlook for people now being diagnosed with thyroid cancer. The numbers were published in 2010 in the 7th edition of the AJCC Cancer Staging Manual. They are based on the stage of the cancer when the person is first diagnosed. Papillary thyroid cancer* Stage 5-Year Relative Survival Rate I Near 100% II Near 100% III 93% IV 51% *Based on patients diagnosed 1998 to 1999 Follicular thyroid cancer* Stage 5-Year Relative Survival Rate I Near 100% II Near 100% III 71% IV 50% *Based on patients diagnosed 1998 to 1999 Numbers provide an overall picture, but keep in mind that every person is unique and that statistics can’t predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your case best. How is thyroid cancer treated? About treatment Depending on the type and stage of your thyroid cancer, you might need more than one type of treatment. Doctors on your cancer treatment team may include:

• A surgeon: a doctor who uses surgery to treat cancers or other problems

• An endocrinologist: a doctor who treats diseases in glands that secrete hormones • A radiation oncologist: a doctor who uses radiation to treat cancer

• A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer Many other people may be part of your team as well, including physician assistants, nurse practitioners, nurses, psychologists, and social workers.

After thyroid cancer is found, your doctors will discuss your treatment options with you. It is a good idea to take time to think about each of them. In choosing a treatment plan, things to take into account include the type and stage of the cancer and your overall health.

The treatment options for thyroid cancer might include:

• Surgery

• Radioactive iodine treatment

• Thyroid hormone treatment

• External beam radiation treatment

• Chemotherapy The best approach often uses 2 or more of these methods. Most thyroid cancers can be cured, especially if they have not spread to distant parts of the body.

If a cure is not likely, the goal of treatment may be to remove or destroy as much of the cancer as possible and to keep it from growing, spreading, or coming back for as long as possible. Sometimes treatment is aimed at relieving symptoms such as pain or problems with breathing and swallowing. This treatment is called palliative care. Thinking about taking part in a clinical trial Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases, they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they are not right for everyone. If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service at 1-800-303-5691 for a list of studies that meet your medical needs, or see the Clinical Trials section on our website to learn more. Considering complementary and alternative methods You may hear about alternative or complementary methods that your doctor hasn’t mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few. Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be dangerous. Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known (or not known) about the method, which can help you make an informed decision. See the Complementary and Alternative Medicine section of our website to learn more. Help getting through cancer treatment Your cancer care team will be your first source of information and support, but there are other resources for help when you need it. Hospital- or clinic-based support services are an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help. The American Cancer Society also has programs and services – including rides to treatment, lodging, support groups, and more – to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists on call 24 hours a day, every day. The treatment information given here is not official policy of the American Cancer Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor. Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options. The next few sections describe the types of treatment used for thyroid cancers. Surgery for thyroid cancer Surgery is the main treatment for nearly every case of thyroid cancer, except for some anaplastic thyroid cancers. If thyroid cancer is found by a biopsy (fine needle aspiration), surgery to remove the tumor and all or part of the rest of the thyroid gland is most often done. Lobectomy In this operation, the lobe with the cancer is then removed, usually along with the small piece of the gland that acts as a bridge between the left and right lobes (the isthmus). Lobectomy is sometimes used to treat thyroid cancers that are small and that show no signs of spreading beyond the thyroid gland. It is also sometimes used to diagnose thyroid cancer if a needle biopsy result doesn’t provide a clear diagnosis. Thyroidectomy In this operation, the entire thyroid gland is removed. This is the most common surgery for thyroid cancer. Lymph node removal If the doctor suspects spread of the cancer to nearby lymph nodes in the neck, these will be removed at the same time surgery is done on the thyroid. Sometimes only one or two lymph nodes are enlarged and need to be removed, but more often, several lymph nodes near the thyroid are removed. Risks and side effects of surgery Patients who have thyroid surgery are often ready to leave the hospital the next day. Possible problems from thyroid surgery include:

• Hoarseness or loss of voice that may be short term or permanent.

• Damage to the parathyroid glands (small glands near the thyroid that help control blood calcium levels). This can lead to low blood calcium levels, causing muscle spasms and numbness and tingling  feelings.

A cancer that develops in the breasts is known as breast cancer. It can occur both in men and women, but is more prevalent in women.

How does breast cancer develop?

Breast cancer starts when cells in the breast start to multiply in an uncontrolled fashion, first growing locally and then spreading to axilla and later to other body parts most commonly bones, liver and lungs. There are two main types of breast cancer:

  1. Ductal carcinoma: It is a type of cancer that originates in the milk ducts. (common)
  2. Lobular carcinoma: It is a type of cancer that originates from lobules, where milk is produced.

What causes breast cancer?

The exact cause for development of breast cancer is not known yet but there are multiple risk factors which increases the chance for development of breast cancer as mentioned below

  1. Age:It is the one of the most important and unchangeable risk factor for breast cancer development. There is increase in the breast cancer risk as the age increases. Most of the breast cancers are seen in elderly population ( more than 50yrs) butcancer incidence in younger women is also increasing and it is seen in age as early as 22 to 25 yrs.
  2. Female sex: it is one of the biggest risk factor for breast cancer development. It is about 100 times more common in women than among men.
  3. Family history and Genetic causes: Hereditary plays a vital role in breast cancer development. Upto 10 to 15% newly detected cancer has family history and areBRCA1, BRCA2 or other mutation positive. This patient are younger in age and multiple family relatives suffering from different cancers or they may be the index case for that family.If you’ve had one first-degree female relative (sister, mother, daughter) diagnosed with breast cancer, your risk is doubled.
  4. Personal history of breast cancer : If a woman has a history of breast cancer then, there are higher chances of developing new cancer in same or another breast.
  5. History of radiation exposure to Chest or Face Before Age 30: Patient receiving radiation to the chest for treatment of another cancer like Hodgkin’s disease or non-Hodgkin’s lymphoma, have a higher-than-average risk of breast cancer.
  6. Changes in the breast: Certain non-cancerous changes in the breast increases the risk of breast cancer increasing the risk. Having Dense Breasts also increases the risk by 6 times.
  7. Race/Ethnicity: White women are slightly more likely to develop breast cancer than African American, Hispanic, and Asian women.
  8. Overweight and obese women have a higher risk of getting breast cancer when compared to normal weighted women, especially after menopause. It also increases the chance of recurrence of cancer or development of new breast cancer.
  9. Early menarche and late menopause: it increases the exposure of women to number of cycles thus increasing the risk.
  10. Pregnancy History and breast feeding: Women who haven’t had a full-term pregnancy or have their first child after age 30 have a higher risk of breast cancer compared to women who gave birth before age 30.Breastfeeding can lower breast cancer risk, especially if a woman breastfeeds for longer than 1 year.
  11. Using HRT (Hormone Replacement Therapy) it increases the risk.
  12. History of smoking and Alcohol intake increase the risk.
  13. Exercise: Moderate or intense level for 4 to 7 hours per week reduces breast cancer risk.

What are the symptoms of Breast Cancer?

Breast cancer is usually symptomatic in late stages. Very early breast cancer may not show any symptoms hence, regular breast self-examination, examination by clinician and screening tests are important to detect such earlier stage cancers.

Contact a doctor (preferably an oncologist) if you experience any one of the following symptoms:

  1. A lump in a breast.
  2. Change in the size and shape of the breast or nipple.
  3. Sunken or inverted nipples.
  4. The peeling of nipple skin or breast skin (skin ulcers).
  5. Discharge from the nipples (it may contain blood).
  6. A pain in the armpits or breast (which is not related to the woman’s menstrual period).
  7. Redness of the skin of the breast.
  8. A swelling in one of the armpits.
  9. Bone pain and body pains when associated with above symptoms.
  10. Drastic weight loss.

What are the tests required to evaluate breast cancer?

The following tests are required to diagnose and evaluate breast cancer:

  1. Breast imaging – bilateral breast mammogram and/or breast ultrasound.
  2. Biopsy – core/ open – HPE, ER, PR and Her 2 status / FNAC from the lump.
  3. Metastatic evaluation (to evaluate disease spread) – for very early cancers no tests are required. For delayed cancers – X ray chest PA view + USG abdomen + Bone scan/ CECT thorax and abdomen + bone scan/ PETCECT are required.
  4. Routine blood investigation to asses’ fitness of the patient for treatment.

How is breast cancer treated?

Treatment of breast cancer is by multimodality method i.e. Surgery, Radiation Therapy, Chemotherapy, Hormonal therapy.

In early stages the treatment is order of Surgery +/- Chemotherapy +/- Radiation Therapy+/- Hormonal therapy. But in later stages Neoadjuvant Chemotherapy à Surgery à Completion Chemotherapy à Radiation Therapy +/- Hormonal therapy.

In stage IV disease the local treatments like surgery and radiation therapy plays a role only in palliative settings and the cancer is mainly treated by chemotherapy and hormonal therapy.

What are the different types of surgical options?

  1. Modified Radical Mastectomy (MRM): in this procedure the whole of the cancer containing breast  and the axilla is removed with a single elliptical incision on the breast. At the end of surgery the patient doesn’t have the whole same side breast but the opposite breast is retained. The chest is flat on the operated side.
  2. Breast Conservation Surgery (BCS): this is done for very early breast cancer patient where the tumor is very small in size. The cancer with adjacent normal tissue is removed with an elliptical incision around the lump and axillary lymph node dissection is done with an another incision in the axilla.

When the cancer is in the breast why are you removing the axillary lymph nodes?

Breast cancer spreads to the axillary lymphnodes first and then to rest of the body so they have to be removed to look for their involvement. Axillary lymphnode dissection is therapeutic, helps in staging and also prognostic.

Which is the best surgery – MRM/ BCS?

Both types of surgeries are equally good for the treatment of breast cancers. For advanced diseases MRM is done. For early breast cancers both BSC and MRM can be done. If  BCS is done, there is 2-3% increase risk of local recurrence when compared to MRM. Systemic recurrence does not change based on the type of surgery.

What will happen if I don't undergo surgery?

The cancer will grow in size, at first eating away the breast and later will spread to the axilla and to the whole body. The life of the patient decreases as the cancer stage increases and the cancer spreads to the different body parts.

What are the complications of surgery?

Surgery for breast cancer though considered to be a major surgery but has very few complications like infection, flap necrosis, seroma formation, loss of sesation on the chest wall and axilla, bleeding and few anesthesia related complications. Usually the patients are started on oral diet within 6 hrs, ambulated with in the same day and discharged in 2 days with drain insitu.