Gynecological Cancer – 3
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for covering HPV vaccine and PAP smear role in prevention of cervix cancer and diagnosis in precancerous stage. It was astounding to note that application of even on of these measures India wide can save about 1 lac lives a year.
Probably even more surprising for me was the fact that CHEMORADIATION gives better results compared to surgery in cervix cancer, including stage IB2 to 4. We always thought that for all solid tumors, surgery is always the better option.
Ans: Thank you. Yes, unfortunately awareness related to cancer treatment options is still limited. Hence most doctors also think the same way that surgery is always first treatment for solid tumors.
In fact, for many solid tumors, surgery has been replaced by chemoradiation as first option or at least an equal option. For example, majority cancers of Base of Tongue, Pyriform fossa, Larynx, Nasopharynx, upper third of esophagus and even many cases of middle third, lung cancer in stage 3, anal canal. Additionally, some cases of bladder cancer and other sites can be treated by chemoradiation as an organ preserving option, without surgery. There are ongoing trials for other sites as well.
Also, for many sites or stages, chemoradiation is to be done first or chemotherapy first, to be followed by surgery. Important point being, surgery is NOT always FIRST.
This is however possible only by close interaction and team work between all three specialists – medical oncologist, radiation oncologist and surgeon. To facilitate this team work, all good cancer centers have concept of “Tumor Board”. This is a multidisciplinary discussion group, where all concerned specialists discuss cases to determine best course of treatment for an individual patient. It also allows patient to obtain best opinion without actual need to see all three specialists just to decide treatment.
It is also important to remember that solid tumors are rarely emergency. Vast majority of patients can easily wait for few weeks to determine best option, rather than jump to surgery or any other form of therapy as soon as diagnosis is made. Please do remember that in USA or Europe, it takes few weeks easily for patients to go through each appointment, insurance approval, treatment appointments, operation theater booking etc. And yet, there results are better. Planning is more important, than speed of treatment in most cases.
IF READERS CAN PASS ON THIS MESSAGE TO THEIR PATIENTS AND OTHER DOCTORS, it will add significantly to overall better cancer care.
Que: That is truly a very important message for improving overall cancer care. We need to come out of this panick and act quickly mindset. So that our patients can find better and even cheaper care. Now Chiragbhai, what about advance cancer of cervix, beyond surgery or chemoradiation?
Ans: Metastatic or advance stage 4 cancer remains a bad disease, with limited options, and limited life span. Average survival is less than a year.
Like most other cancers, we look for subsets with very limited disease, such as only para aortic nodes (where radiotherapy or chemotherapy may sometimes provide long disease control); single or few resectable lung metastases.
For most others, palliative chemotherapy is used. For patients with good fitness, combination carboplatin (or cisplatin) and paclitaxel is better option. Bevacizumab, a monoclonal antibody with anti angiogenesis property can be added to chemotherapy for better response rate and survival. However this is an expensive drug, and cost benefit should be taken into account before adding this drug.
For most patients, especially if fitness is not very good, single agent chemotherapy is a reasonable option. Many drugs have activity as single agent, especially if patient has not received any chemotherapy as part of initial treatment. These include paclitaxel, carboplatin, nano particle paclitaxel, docetaxel, pemetrexed, irinotecan, vinorelbine, gemcitabine, topotecan and others. Older agents like 5-FU, methotrexate, bleomycin etc are active but not preferred nowadays due to comparatively poor safety profile.
New treatments like immunotherapy have active ongoing trials, and may possibly of benefit.
More important part of treatment for many of these patients is GOOD PALLIATIVE CARE – such as management of pain, fistula, recurrent infections related to fistula, smell, bleeding etc. Patients should be referred to palliative care centers, as some of these issues are very difficult to manage.
February 14th 2017.
Dr. Chirag A. Shah;
M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com