Cancer-Etiology

Dumb Stuff People Say To People With Metastatic Breast Cancer

Exercise And The Benefits For Cancer Patients

The following article describes in detail the benefits of exercise.

http://www.onclive.com/#

Read and deploy.

Apoptosis-Why We Get Cancer?

As I have mentioned in my previous post there are multiple reasons for getting cancer. We can add diet, smoking, alcohol, viruses, ageing, hormones, polyphenols, benzene, toxins, radiation etc to the list which can contribute in causing cancer.

But to change the perspective let me introduce the concept of apoptosis.

Apoptosis is programmed cell death. To give an example the skin which you have today is not the same as 21 days back. Skin gets new cells every 21 days. Similarly the mucosa in our mouth and intestine changes every day. The old cells die and new ones take their place. The old ones die a planned, programmed death known as apoptosis.

If the cell refuses to die for any reason it becomes a problem. We need a healthy balance between death and birth of new cells in the body.

Apoptosis also plays very important role in our growth. Growth of the baby from single cell to a new born. From new born to infant and from infancy to teenager. At all this growth periods apoptosis plays a very crucial role of controlled, structured, beneficial growth.

Cancer cells become immortal by avoiding apoptosis. Many genes play a role in this apoptosis game. p53, BCL, TRAIL pathway etc. There are many drugs being developed to promote apoptosis of cancer cells.

To just give a philosophical touch...........cells which become too selfish and forget that they have to reside inside an organism become malignant, cancerous. They evade apoptosis but unfortunately kill the body in which they reside. They forget that their selfishness has to be balanced with the survival of the whole organism/body..

Does it strike a chord?

Vaccines In Cancer

We all are aiming and waiting for the day when one can get vaccinated against cancer!

Vaccines can be of two types prophylactic and therapeutic. Prophylactic ones have been developed for few cancers.
Hepatitis B vaccine is predominantly encouraged to prevent oneself from Hepatocellular cancer. This has helped in keeping the rate of liver cancer in check. Liver cancer is a leading problem in China, Taiwan, India etc. In US, hepatitis C infection is expected to create a huge burden of liver cancer in baby boomers. Efforts are on to bring better therapy for hepatitis c.
Another vaccine which has the potential to make an impact is HPV vaccine. HPV vaccines from GSK and Merck are expected to decrease the incidence of cervical carcinoma. There are many types of HPV virus and these vaccines take care of HPV 16, 18. The immunity against these is expected to help fight against other HPV's also. Vaccinated or not, it is highly recommended to get oneself screened for cervical carcinoma.

Provenge, sipuleucel-T, for prostate cancer is a successful therapeutic vaccine for prostate cancer used in metastatic setting.

There are plenty of therapeutic vaccines in clinical trials for lung cancer, head and neck cancer, brain cancer, melanoma.

Next few years are interesting but none of the vaccines are any near to cure.

Reference: http://www.cancer.gov/cancertopics/factsheet/Therapy/cancer-vaccines

Deep Vein Thrombosis & Cancer

Deep Vein Thrombosis (DVT) is a serious complication in many diseases. It is a common post-surgical complication which with the righ prophylaxis is taken care of.

Deep vein thrombosis is clot in the deep vein and when this gets dislodged and move can cause stroke, pulmonary embolism and also damage to heart.

DVT is seen in upto 50% of cancer patients but unfortunately is underdiagnosed. DVT in cancer patients can be because of various reasons. Some cancers like lung, colon, ovary, pancreas, stomach and endometrium have greater risk of DVT because of increased viscoity of blood. Few treatments can increase rik of DVT, example tamoxifen.

DVT can present insidiously. At times one can have redness, pain when the veins in the thigh are involved. If pulmonary embolism ha happened there can be dry cough, breathlessness.

Any perosn with cancer needs to be aware of DVT and should ask his treating Oncologist about the same and be on vigil.
Primary and seconadry prophylaxis have their own challenges. One needs to tell the treating phyician about all the medications one is taking as drug interactions are very common.

Take home message is:

1. Be on vigil
2. Drug interactions are common, so ask your doctor about the same when you are taking multiple medications.
3. Be active, exercise helps blood circulation and also in many other ways.
4. Be hydrated always.
5. Take extra precautions on long haul flights.

Be aware and ask right questions!

References:

1. http://www.cancerresearchuk.org/cancer-help/about-cancer/cancer-questions/cancer-and-the-risk-of-blood-clots

2. http://annonc.oxfordjournals.org/content/16/5/696.long

3. http://www.telegraph.co.uk/health/healthnews/9357487/Blood-clot-patients-to-receive-routine-cancer-checks.html

4. http://www.cancer.gov/ncicancerbulletin/062910/page5

5. http://www.webmd.com/cancer/features/exercise-for-cancer-patients

Epigenetics

Among the many topics which i like to debate about, Nature versus Nurture holds a special place. It can also be called as debate of free will verus determinism. Will ponder more about that in some other post.
Today would like to bring attention to "Epigenetics". A very interesting field which kind of favors nurture theory or on second thoughts does it!!.
Let me get this by posing few questions.

1. Does our diet have an influence on our children?

2. Can I blame my health condition on my mother for what she ate or did not eat during pregnancy?

3. How do our genes learn from our experiences? How is the information incorporated into the DNA?

4. How does from a single cell embryo we become complex human beings? How does the stem cell know to become eye or ear or cardiac cell?

5. How does my nutrition and my environment influence the expression of my genes?

6. Why are identical twins different in terms of characteristics, behavior preferences?

7. Can anxiety or calmness be related to the amount of cuddling and care you received during infancy?

The answer to above question partly lies in epigenetics.

Excellent site to learn is http://learn.genetics.utah.edu/content/epigenetics/

But answers with my bias and understanding are:

1. Yes, our diet has an influence. If your paternal grandfather had food abundance you may have a shortened lifespan!!

2. During early embryonic period it is very crucial for mothers to have balanced nutritious diet (vitmin B complex, folic acid etc.). Lack of key nutrients can increase risk of obesity, cancer and diabetes.

:) Boys, men eat less and feed the women properly!

3. Our experiences can be tagged to DNA by processed called as methylation and acetylation. They are prone to change. Toxins have detrimental effect by acting on these processes.

4. By epigenetics cells become destined organs! (Language)

5. Even for adults having methyl ric food is beneficial. Food guide.

6. The genes may be same but the expression is different because of epigenetics. Also the genes are not same!!

7. Yup, if we extrapolate data from rats. Pup which is licked for first week is more calm. But we do not want the whole world to be full of Buddhas (Monks).

In another post will try to focus on role of epigentics in cancer and how this is being targeted to fight cancer.

Diabetes and Cancer

Chronic diseases are the scourge of the new age. All over the world people living with diabetes are expected to increase, especially in India.
Epidemiological studies indicate an increased risk of cancer for diabetic people. There is increased risk of hepatocellular cancer, pancreatic cancer, breast cancer, endometrial cancer, colorectal cancer, stomach cancer and bladder cancer. Prostate is the odd guy out as the risk for it is decreased if you have diabetes (possibly because of low testosterone levels).
The causal relationship between diabetes and cancer is not well established. There may be confounding bias, observational bias as the evidence is epidemiological. There are few biological hypothesis. Hyperinsulinemia drives growth and diabetics have hyperinsulinemia. Also cancer cells express IGF-1 (Insulin like growth factor receptors) receptors. Inflammation is more common in diabetics and chronic inflammation is a risk for cancer.
Summary and Actions To Be Taken:

1. Epidemiological evidence is there to say that diabetics are at increased risk for cancer.

2. Causal relationship and biological mechanism still needs further elucidation.

3. Diabetes and cancer share several risk factors, like obesity and physical inactivity. An effort to prevent and control diabetes will have a positive effect on cancer incidence. One need not have to wait for conclusive evidence to implement healthy habits and preventive measures.

4. Researchers and clinicians need to be more aware and collect prospective data. Also design studies to benefit patients.

5. The cancer risk conferred by diabetes may be moderate but considering that 366 million people have diabetes worldwide and it is expected to reach 552 million by 2030 calls for awareness and action.

Reference: Diabetes mellitus and cancer risk: Review of the epidemiological evidence

Second Opinion-A Story Of Cervical Cancer Patient

January is the Cervical Cancer Awareness Month, let me share a story of one of my patient.

One afternoon in 2007 post lunch, I had a knock on the door. It is a common practice for patients, patients relatives to seek consultation at doctor's residence. They normally would be from nearby village and the need to catch bus/train back home compels them to disturb doctor during his personal/private time.

This time it was a bunch of people with MRI scan and other reports in hand. The MRI showed mass in the cervical region extending into the bladder. MRI is not a part of FIGO staging but widely done scan. There is a learning curve to interpret MRI's and I had to rely on the report given by Radiologist to get more out of the MRI report. The description mentioned cervical mass invading the bladder. The histopathology report had confirmed it as squamous cell carcinoma. They had consulted a gynecologist who based on the reports had counselled them that it was Stage 4 cervical cancer and the best treatment would be symptomatic care. Looking at the reports, I also opined that it is Stage 4, Surgery and Radiation both would cause more harm. Benefit from chemotherapy is doubtful. One of the relative insisted on getting the patient examined by me. I reluctantly agreed. 

The same day evening I examined the patient. On pelvic examination, to my surprise, found the anterior fornix completely free. You cannot have the bladder invaded with the tumor without the anterior fornix being involved. The physical examination did not match the MRI report. The clinical diagnosis was Cervical cancer stage II B. This was potentially treatable and curable. But what was that in the bladder? 

CT scan and Urology opinion made us realize that it was a big stone in the urinary bladder.

The patient had surgery for the removal of the stone. When the wound had healed she received Radiation both external and brachytherapy. During external radiation she also received weekly Cisplatin chemotherapy. 

It is five years now since she got treated.  She has occasional urinary tract infection has subcutaneous fibrosis. Probably she can be considered cured of her cancer. Last year her third son got married and he was quite emotional.

The patient and her family hail from the rice growing region in Karnataka. They have constantly shown their gratitude by supplying me with free rice. I call her lucky and i am even more lucky!

Learning:

1. Clinical examination is a must. Scans cannot substitute clinical examination.

2. It is a good idea to get second opinion.

3. PAP Smear screening will reduce/eliminate diagnosis at late stage. Early stage diagnosis or pre malignant lesions are completely curable.

"Cancer is curable, if treated early".

Godspeed!

Inequality in Cancer Clinical Trials

In past few weeks multiple instances have prompted me to ponder over inequalities in life. Those interested in them can read here and here.
A recent article published in JCO talks about inequality in recruitment of patients for clinical trials. It is well know that older patients are underrepresented in clinical trials. This get compounded further if they are economically poor. In short poor, elderly patients do not get to participate much in clinical trials. Also if you are less educated chances are you will not participate in a clinical tril.

Musings:
1. Older population needs to be adequately represented in clinical trials to ensure that in "real life" they do not suffer. This is essential for many reasons like, their cardiac, renal reserves are different from young patients. So the effect of drugs need to be know in older patients. Also they are on multiple medications and drug interactions are a common problem.

2. Why income is a barrier to participate in clinical trials? This needs deeper thought. Referring physicians need to be made more aware to ensure patients participation in clinical trials.

A long way to go................