How common is head & neck cancer?

It's the 6th most common cancer worldwide. In India it comprises 40% of all cancer. Generally it is an ailment of the elderly (>50yrs of age) though recently there has been a steady increase in incidence in younger generation.

What causes head & neck cancer?

Tobacco in any form (viz. cigarettes, cigars, bidis, chewing tobacco, catechu, lime, betel nut, marijuana) and alcohol are the major causes. Combination of tobacco and alcohol increases the risk for HNC by 85%.

What are the symptoms of Head & Neck Cancer?

Symptoms of HNC vary according to the site of origin of cancer. Head & neck cancer very often presents without any warning sign/ symptom. Because of this characteristic, patients with HNC often presents with advanced disease -a fact that makes annual cancer screening important in people over 40 years of age, especially if they are addicted to tobacco and/ or alcohol. The presence of any of the following, if present for more than a period of two weeks mandates a visit to the Head & Neck Surgeon:
	A sore/ ulcer on the mouth/tongue or lip that does not heal even after taking antibiotics
	A white or red patch on the gums, tongue, lining of the mouth
	Inability to protrude the tongue
	Inability to open the mouth properly
	Swelling of the gums that causes dentures to fit properly
	Unusual bleeding, pain or numbness in the mouth or in the cheek
	Thickening of the cheek
	Sudden spurt of loose teeth
	Slurred speech
	Earache
	Feeling of something getting stuck in the throat/ a sore throat that does not go away
	Change in voice/ hoarseness
	Painful and/or difficulty in swallowing
	Difficulty in breathing
	Swelling around and/or under the jaw which may be accompanied by numbness or paralysis of one side of the face
	Weight loss
	Swelling in the midline of the lower neck which moves with swallowing
	Progressively enlarging lumps in the neck

How are head & neck cancer diagnosed?

When a patient is suspected with head & neck cancer, the examining surgeon evaluates the medical history and performs detailed physical examination before subjecting the patient to other diagnostic tests depending upon the area of suspicion. A biopsy (study of a tissue sample from the suspected area under the microscope) is mandatory to confirm diagnosis of cancer.

What is cancer staging and how does it help?

Once the diagnosis of cancer is confirmed the patient is then staged. Staging gives information regarding the extent of the cancer and helps the clinician in planning the treatment.

What are the treatment options of head and neck cancer?

Surgery, radiotherapy (radiation) and chemotherapy are the three modalities of treatment of head & neck cancer. Surgery and/ or radiotherapy are the primary modalities while chemotherapy is used as adjunct/adjuvant treatment. The treatment plan varies from patient to patient depending on a number of factors like the stage of the tumor, location of the tumor, patient's general condition, patient's age, occupation of the patient, the geography of the patient's hometown.

Surgery: The surgeon removes the cancerous part along with some healthy tissue around it. In most of the head and neck cancer surgery an accompanying dissection of the regional (neck) lymph nodes is necessary.

Radiotherapy (radiation therapy) entails use of high energy x-rays to kill cancer cells. The source of radiation may be from a machine outside the body (external beam radiotherapy) or from radioactive materials inserted into the involved organ (brachytherapy).

Chemotherapy is the use of anticancer drugs and is used to kill cancer cells throughout the body.

What are the side-effects/ sequelae of head & neck cancer treatment?

Surgery: Head and neck cancer surgery, which is the primary modality of treatment in most instances often, changes the patient's ability to chew, swallow or speak. It may also results in alteration of the patient's appearance. Immediately after the surgery the face and the neck may be swollen, which slowly subsides in a few weeks time. But an accompanying neck dissection, which is often the case, slows down the flow of lymph from the face and this may result in prolonged mild to moderate swelling of the face. The consequence of surgery is site specific viz. loss of jaw in case of oral surgery, loss of voice in cancer of the throat. In the recent past advances in reconstructive and plastic surgery has made a lot of positive impact on the quality of life in the post surgery period.

Radiotherapy: Radiotherapy in addition to killing the tumor cells also has a deleterious effect on the adjacent tissue which results in some unwanted side-effects. During the treatment period the patient may experience redness, irritation, sores in the mouth, thickened saliva, and changes in taste and/or nausea. After radiation patient may suffer from such long term effects like decrease in taste, changes in the texture of the skin, stiffness of the jaw.

It should be remembered that each situation is unique and side-effects vary from patient tot patient, even though they may suffer from same type of disease. It is always advisable to discuss the side-effects with the concerned physicians and support staff like the attending nurse, dietician, and swallowing therapist.

At present many clinical trials (called supportive care trials) are being conducted to establish better ways to reduce the side effects of chemotherapy and radiotherapy so as to improve the quality of life of head and neck cancer patients.

How is a head and neck cancer patient rehabilitated?

Rehabilitation, after aggressive cancer treatment is an important aspect of head and neck cancer management. The goals of rehabilitation depend on the location of the tumor, extent of the disease and the type of treatment the patient has received. Depending on various factors (cited above) rehabilitation may include physical therapy, dietary counseling, speech & swallowing therapy, care of stoma (opening in the lower neck through which a patient breathes after laryngectomy), psychological counseling etc. Successful rehabilitation involves a team work. On the patient's part it is always beneficial to communicate with a cancer survivor (which can be done with the help pf the attending physician or the nursing staff). We at Max Cancer Centre provide a number of support services like physical therapist, clinical psychologist, speech therapist, social worker, prosthodontist, and specially trained nursing staff for the betterment of quality of life of head and neck cancer survivors.

How is a head and neck cancer patient monitored/ followed-up?

After completion of cancer treatment it is very much important to have regular check-up or follow-up visits so as to detect early recurrence or a second cancer, if there is any. Depending on the treatment received the patient may undergo physical examination and/or imaging studies or other laboratory tests. It is very much necessary on the part of the patient to quit smoking and/ or alcohol since studies has shown that persisting with these habits after treatment completion reduces the effectiveness of treatment and increase the chance of a second primary cancer. Follow-up visits are usually advised::
	Every 4-6 weeks for the first year
	Every 8weeks for the second year
	Every 12 weeks for the third year
	Every 6 months for the fourth and fifth years
	Once in a year thereafter

Why did my child get cancer?

In most cases cause is unknown. In some cases there is associated genetic abnormality and environmental risk factors.

How long has the cancer been there ?

It is not possible to determine when the cancer started.

How successful is the treatment for childhood cancer?

There has been a dramatic improvement in the treatment of childhood cancer. The survival rate has increased to 79% (1996-2003).

How long the treatment will last?

The treatment is a multimodality treatment including chemotherapy, surgery and radiation therapy depending on the type and stage of the disease. The treatment is usually prolonged and it depends on the type and stage of cancer. After completion of treatment child should remain on long term follow-up.

What are the suspected causes of childhood cancer?

Cause of childhood cancer is largely unknown. Genetic factors (Down's syndrome and other genetic abnormalities) explain a small percentage of cases. Some environmental factors suspected as risk factors include exposure to ionizing radiation, pesticides, benzene and certain chemotherapeutic drugs. Certain viral infections are also been suspected as risk factors (EB virus, HTLV and HIV).

Is Breast Cancer infectious?

No. Breast Cancer is not infectious. You cannot catch breast cancer.

Can Breast Cancer be caused due to stress?

Stress/injury to the breast does not cause breast cancer.

What are the risk factors of Breast Cancer?

Some of the risk factors of Breast Cancer include age, family history, obesity, hormonal profile, diet, oral contraceptives, HRT, etc.

What are the symptoms of Breast Cancer?

Breast cancer commonly presents as a lump in the breast, nipple discharge, nipple retraction or dimpling of skin.

Where can Breast Cancer spread?

Breast cancer spreads to the glands in the armpit, root of the neck, in the chest (Lymphatic spread) or it may also spread inside the body to organs like lungs, liver, bones, ovaries and brain-Metastatic Breast Cancer (Hematogenous spread).

What are the Treatment Options?

The Treatment options are planned after an accurate diagnosis and proper staging of the disease is complete. There are several modalities of treatment which can be very beneficial if the cancer is diagnosed at an early stage. These include surgery, chemotherapy, radiation therapy and hormonal therapy. These are usually used in combination based on the stage of the breast cancer, menopausal status or presence of hormone receptors(ER/PR) in the tumor.

Does one have to sacrifice the breast?

One doesn't always have to sacrifice the breast. Depending upon the stage of disease you can choose from Breast conservation surgery where a wide excision of lump with removal of axillary nodes and radiation therapy and you may have a near normal breast at the end of the procedure or Modified Radical Mastectomy which is the removal of the entire breast along with the lining over the chest muscles & removal of axillary lymph nodes. MRM is recommended when cancer is found in more than one part of the breast or the breast is small or a woman says no to radiation therapy.

What are the surgical risks or post-operative problems?

As with any kind of surgery, one is faced with the risk of infection, poor wound healing, fluid collection under the skin or armpit, tingling or numbness along the arm, stiffness of the shoulder, swelling of the arm, etc.

Does everyone need Chemotherapy?

Research suggests chemotherapy may be given only if any lump more than 1 cm may have spread outside the breast.

What are the side effects of Chemotherapy?

The short term side effects of Chemotherapy include loss of appetite, nausea & vomiting, diarrhoea or constipation, fatigue, weight changes, mouth sores/sore throat and hair loss. The long term side effects are weakening of the heart, damage to ovaries, infertility, early menopause, second cancers such as leukaemia.

Can you get pregnant during Chemotherapy?

Although your periods may stop during chemotherapy but you can still get pregnant, so adopt a safe birth control method in consultation with your doctor.

What is Radiation Therapy?

Radiation Therapy is a method of using high energy X-rays to destroy cancer cells that may still be present in the affected breast or nearby lymph node. The usual schedule for radiation is 5 days a week for 5-6 weeks and the actual sitting takes only a few minutes each day.

What is Hormonal Therapy?

Hormonal Therapy is a method used to attack those cancers which depended on natural hormones to grow. If the tumor is reported as estrogen receptor or progesterone receptor positive, it is logical to think that any remaining cancer cells may continue to grow in the presence of these hormones. Hormonal therapy blocks the body's natural hormones from reaching any remaining cancer cells.

What is cancer?

Cancer develops when cells in a part of the body begin to grow out-of-control. Although there are many kinds of cancers, they all start because of out-of-control growth of abnormal cells.

Lung cancer

Lung cancer usually begins in the lining of the airway. A cancer that starts in the cells lining an organ is called a carcinoma. There are different types of lung cancers. Based on biological behaviour and for the purpose of treatment decisions, they are classified as : small cell carcinomas and non-small cell carcinomas. Small cell carcinomas are also called oat cell carcinomas because of the shape of the cell. Unfortunately, it spreads early and causes few early symptoms. Non-small cell carcinomas include squamous cell carcinoma, adenocarcinoma, large cell carcinoma, bronchiolo-alveolar cell carcinoma etc.

Causes of Lung cancer

	Smoking (Up to 90 per cent of lung cancers are caused by smoking)
	As with many cancers, we do not know the cause in all cases. Also linked to lung cancer are contact with asbestos, steel, nickel, chrome and coal gas processing
	Exposure to radiation increases the risk of all cancers, including lung cancer. Miners of uranium, fluorspar and haematite may be exposed to radiation by breathing air contaminated with radon gas

How common is Lung cancer in India?

Lung cancer is the commonest cancer in India in males. Majority of patients present are in advanced stages because the index of suspicion for lung cancer is low. The symptoms of lung cancer, like most other cancers are vague and overlap with infective conditions and other benign diseases. We encourage people to get investigated if any symptom persists for more than 4 weeks and also before starting any imperial treatment through our 'Max Cancer Alert Programme.'*

*Ask for Max Cancer Alert Programme Information Literature at the Help Desk

Diagnosis

Some people have symptoms on routine health check-up (screening X-ray picks up a lung lesion). The most common symptom of lung cancer is a cough that won't go away or a change in a chronic cough. Shortness of breath, bloodstained sputum, chest pains and repeated bouts of pneumonia or bronchitis may also be signs of lung cancer. Other symptoms include fatigue, loss of weight, wheezing (due to a blockage in the windpipe), hoarseness or difficulty in swallowing. There may also be symptoms that seem unrelated to the lungs. These may be caused by the spread of a lung cancer to other parts of the body.

How Lung cancer is diagnosed ?

Your doctor will first ask you about your past and current health, smoking and work history and do a physical examination. Doctors may suggest that you undergo some of the following tests.

Chest X-ray

This is generally the first investigation for any respiratory symptom. It works only as a screening tool.

Computerised Tomography (CT) scan

A CT scan is a type of X-ray that gives a cross-sectional picture of organs and other structures (including any tumours) in your body. It can be used to see smaller tumours than those found by X-rays. It can also show if lymph nodes are enlarged or if the cancer has spread to other organs.

Sputum Cytology

This test is an examination of sputum under a microscope to check for abnormal cells. Sputum is the thick fluid you cough up from your lungs. At least three serial cytological studies should be done on different days to make any conclusive decision.

Bronchoscopy

This allows the doctor to look at your lungs and windpipe and take a sample of tissue (biopsy) with the help of a bronchoscope. It can be uncomfortable but is not painful and can be done as a day care procedure under local anaesthesia and sedation. With this the bronchial tree can be assesed, not beyond it. Only in about 1/3rd of the cases, there will be a significant finding in Bronchoscopy.

Fine-needle aspiration

This allows the doctor to take a sample of tissue from a lesion that cannot be sampled using bronchoscopy. It is usually done as an outpatient procedure. You will have a local anaesthetic. The doctor will insert a needle through your chest wall and into the lesion under CT guidance and aspirate some tissue.

Positron Emission Tomography (PET)

Positron Emission Tomography, also known as a PET scan, involves the injection of radioactive glucose solution into the body. PET-CT appears to be the most accurate method for detecting cancer spread to areas other than the brain. However, PET scan cannot differentiate between cancer and infection. Generally speaking, one should validate the PET scan finding by biopsy or FNAC before taking a final decision.

MRI Brain

MRI Brain is also conducted as a part of staging procedure for lung cancer patients in specific conditions.

Mediastinoscopy

In this test, the doctor is able to look at lymph nodes in the centre of the chest, to see if they are affected by cancer. The procedure is similar to Bronchoscopy, but the tube is inserted through a small cut in the neck and fed down to the lymph nodes around the windpipe. The doctor can remove a sample of tissue (biopsy), if necessary. This requires general anaesthesia and preferably admission for a day.

Bone scans

You may have some other types of scan. A bone scan can show whether cancer has spread to the bones. Ventilation/perfusion lung scans can calculate how much lung function will be lost if lung tissue is removed.

Other tests

You may also have blood tests and breathing tests. If surgery is an option, it is very important to measure your breathing capacity by Pulmonary Function Test (PFT). People who smoke develop emphysema and may have a reduced breathing capacity. Ventilation & Perfusion : A Cardiologist is also asked to assess the cardiac function.

'Staging' the disease

The tests described above show whether you have cancer. They will also show where the primary cancer is and whether the cancer cells have spread to other parts of your body. This helps your doctors 'stage' the disease. Staging is necessary for doctors to decide the treatment strategy for you. It is also a guide to prognosis.

Treatment

The main treatments for lung cancer are Surgery, Radiotherapy and Chemotherapy. The choice of treatment will depend on the type of lung cancer you have, stage of disease, whether your lungs are working properly, your general health and what you want.

Surgery

If your cancer has not spread beyond the affected lung and same side of mediastinum, your general health is reasonably good and your breathing capacity is sufficient, the treatment that gives the best chance of cure is surgery. The most common operation, called a Lobectomy, removes the affected part of the lung. Sometimes, the whole lung on the affected side needs to be removed and this is called a pneumonectomy. Another important part of the operation is removal of lymph nodes in the chest without which cancer operation is incomplete.

Thoracoscopy and Video-Assisted Thoracoscopic Surgery (VATS)

This test allows the doctor to see inside the chest and to operate on lung cancer (VATS) or take tissue samples for biopsy, if necessary (Diagnostic Thoracoscopy). Instruments are inserted into the chest cavity through small cuts in the skin. Often the doctor uses a very small video camera and is able to guide the instruments by watching the video screen. You may have up to three to four small cuts made in your chest, one for the camera and others for the surgical instruments. This is performed in suitable cases and provides the advantage of quicker recovery and lesser pain when compared to open surgery.

Chemotherapy

This is the treatment of cancer with anti-cancer drugs. The aim is to destroy cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from multiplying. Chemotherapy is the treatment of choice for patients with small cell carcinoma. In non-small cell carcinoma, you may also have Chemotherapy after surgery to remove the cancer, to increase the chances of cure. This is called 'adjuvant' Chemotherapy. Quite often if the medistinal lymph nodes are affected, 2-4 weeks of neo-adjuvant Chemotherapy is given before the surgery is performed. The team of doctors generally plan the overall treatment; surgery, Chemotherapy and radiation are not alternatives to each other, but, are used in tandem to improve therapeutic outcomes.

Side-effects of Chemotherapy

Some drugs used in chemotherapy can cause side-effects. They may include feeling sick (nausea), vomiting, feeling off-colour & tired and some thinning or loss of hair from your body & head. Generally, these side-effects are temporary, and can be prevented or reduced. Tell your doctor or nurse if you have any of them. The Medical Oncologist will discuss these and other side effects and risks with you.

Radiation therapy

Radiotherapy treats cancer by using radiation to destroy or injure cancer cells. The radiation can be targeted onto cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissue. Newer techniques of Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT) ensure maximum dose to the tumour safeguarding the normal uninvolved organs from adverse effects.

Gated Radiation Therapy for Lung Cancer

This is a highly specialised form of Radiation Therapy where moving tumour such as lung tumour is targeted in a particular phase of breathing cycle. It improves accuracy and reduces side-effects associated with radiation therapy.

Treatment is painless and may take only two to three minutes. Usually, radiotherapy is given as a number of treatments over a period of weeks. Radiotherapy may be used to cure some early stage lung cancers. It may be used with chemotherapy to contain cancers when one is not a suitable candidate for surgery.

Radiotherapy can be used to relieve pain and other symptoms, for example, pain caused by cancer that has spread to the bones or brain. Treatment that is used to relieve symptoms of disease without attempting to cure disease is called palliative treatment.

Targeted therapy (Biological agents)

Some people, usually non-smokers (who have never smoked) are suitable for a new kind of drug that targets the growth genes and/or the blood-vessel forming genes of the cancer cells. These drugs tend to have not as many side effects as the usual chemotherapy drugs, although they can cause rashes. Usually targeted therapy will be used after normal chemotherapy no longer controls the disease. Your doctor may order a special gene test to see if your cancer is susceptible to this type of drug.

Targeted therapy (Biological agents)

Some people, usually non-smokers (who have never smoked) are suitable for a new kind of drug that targets the growth genes and/or the blood-vessel forming genes of the cancer cells. These drugs tend to have not as many side effects as the usual chemotherapy drugs, although they can cause rashes. Usually targeted therapy will be used after normal chemotherapy no longer controls the disease. Your doctor may order a special gene test to see if your cancer is susceptible to this type of drug.

Prognosis

As in most types of cancer, the results of treatment are best when the cancer is detected and treated early. People who have surgery in the early stages of lung cancer have a very good chance of cure. In many people, lung cancer is not found while it can still be operated upon. In people with advanced cancer, palliative treatment with radiotherapy can effectively treat many symptoms.

People who continue to smoke after lung cancer treatment are at risk of further disease. If you would like information about your own prognosis, you need to speak to a doctor who knows your medical history.

Motto of Max Cancer Care

At Max Cancer Centre, we are committed to recuperating our patients as soon as possible. Our dedicated team of leading Oncologists provides the most advanced cancer treatments using cutting edge technology, based on International Standards. Cancer Care requires medical professionals from different specialties to collectively execute an individualised patient care plan for best results. We firmly believe in delivering quality care, support and re-assurance to our patients.

We believe that each patient and his/her disease is unique, hence our team of Oncology experts customise a 'personalised treatment plan' based on the discussions in Tumour Board conferences. We constantly review and improve our protocols and encourage the participation of our patients as well as care givers to understand the disease and its treatment process.

"Back to Life" is how we like to define the intent behind our services at Max Cancer Centre and we prefer to call our program "Max Cancer Care" because we strongly believe that caring for the needs of the patients and care givers is more important than the medical services they avail.

Max Healthcare provides holistic cancer care that includes

	A consolidated review of your case from experts in Surgical Oncology, Radiation Oncology, Medical Oncology and the concerned speciality. This way, hidden costs and multiple inter-departmental visits are curtailed.
	Adherence to the latest international cancer treatment protocols.
	Superior Cancer treatment technology : Max Healthcare is the first facility in Northern India to acquire Novalis Tx for IMRT/IGRT, Radiosurgery, SRS/SRT. The centre is also equipped with facilities for Brachytherapy.
	Complete Cancer Care: Right from cancer screening, early detection, multi-disciplinary treatment to rehabilitation.
	A wider range of medical resources to draw from, with our multi-super speciality back-ups.
	Unique synergy with Neurosciences for Brain Tumours: We are the first cancer care institution in Asia to have the intraoperative MRI BrainSUITETM integrated with Novalis Tx Radiosurgery, which gives us a unique advantage in treating cancers related to the brain.
	Tumour Board: At Max Cancer Centre, a team of our experts from Surgical Oncology, Radiation Oncology, Medical Oncology, Pathology, Imaging and related disciplines come together in the Tumour Board meetings to discuss various cases and form a customised/joint decision on the treatment plan.
This is only for the purpose of information and can not be substituted for medical advice In case of a query, discuss it with your doctor.

What is cancer?

Cancer develops when cells in a part of the body begin to grow out-of- control. Although there are many kinds of cancers, they all start because of out-of-control growth of abnormal cells.

Prostate cancer

The prostate is a walnut-sized gland located in front of the rectum and underneath the urinary bladder. It is found only in men. In older men, the inner part of the prostate (around the urethra) often keeps growing, leading to a common condition called Benign Prostatic Hyperplasia (BPH). In BPH, the prostate tissue can press on the urethra, leading to problems passing urine. Although BPH can be a serious medical problem, it is not a cancer.

Several types of cells are found in the prostate, but over 99% of prostate cancers develop from the gland cells. Gland cells make the prostate fluid that is added to the semen. The medical term for a cancer that starts in gland cells is Adenocarcinoma. Other types of cancer can also start in the prostate gland, including Sarcomas, Small Cell Carcinomas, and Transitional Cell Carcinomas. But these other types of prostate cancer are very rare, therefore, if you have prostate cancer it is almost certain to be an Adenocarcinoma. Some prostate cancers can grow and spread quickly, but most of them grow slowly.

Prostate cancer screening

Prostate cancer can often be found early by testing the amount of Prostate-Specific Antigen (PSA) in the blood. Another way to find prostate cancer is the Digital Rectal Exam (DRE), in which your doctor inserts a gloved finger into the rectum to feel the prostate gland. If the results of either one of these tests are abnormal, further testing is needed to see if there is a cancer. Unfortunately, there are limits to the current screening methods. Neither the PSA test nor the DRE is 100% accurate. Abnormal results of these tests don't always mean that cancer is present, and normal results don't always mean that there is no cancer. Testing with the Prostate-Specific Antigen (PSA) blood test and Digital Rectal Exam (DRE) is done yearly, beginning at age 50, to men who are at average risk of prostate cancer and have at least a 10-year life expectancy.

Prostate-Specific Antigen (PSA) blood test

Prostate-Specific Antigen (PSA) is a substance made by cells in the prostate gland (it is made by normal cells and cancer cells). Although PSA is mostly found in semen, a small amount is also found in the blood. Most healthy men have levels under 4 nanograms per milliliter (ng/mL) of blood. The chance of having prostate cancer goes up as the PSA level goes up. When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not mean that cancer can not be present.
The PSA level can also be increased by things other than prostate cancer, such as:
	Benign Prostatic Hyperplasia (BPH) - a non-cancerous enlargement of the prostate that many men get as they grow older.
	Age - PSA levels will also normally go up slowly as you get older, even if you have no prostate abnormality.
	Prostatitis - an infection or inflammation of the prostate gland.

Digital Rectal Exam (DRE)

For a Digital Rectal Exam (DRE), a doctor inserts a gloved, lubricated finger into the rectum to feel for any bumps or hard areas on the prostate that might be cancer. The prostate gland is found just in front of the rectum, and most cancers begin in the back part of the gland, which can be felt during a rectal exam.

Signs and symptoms of prostate cancer

Early prostate cancer usually causes no symptoms and is most often found by a PSA test and/or DRE. Some advanced prostate cancers can slow or weaken your urinary stream or make you need to urinate more often. But non cancerous diseases of the prostate, such as BPH (Benign Prostatic Hyperplasia) cause these symptoms more often. If the prostate cancer is advanced, you might have blood in your urine (hematuria) or trouble getting an erection (impotence). Advanced prostate cancer commonly spreads to the bones, which can cause pain in the hips, spine, ribs, or other areas. Cancer that has spread to the spine can also press on the spinal nerves, which can result in weakness or numbness in the legs or feet, or even loss of bladder or bowel control. Other diseases can also cause many of these same symptoms.

Prostate cancer diagnosis

If certain symptoms or the results of early detection tests like the Prostate-Specific Antigen (PSA) blood test and/or Digital Rectal Exam (DRE) suggest that you might have prostate cancer, your doctor will do a prostate biopsy to find out if the disease is present.

Prostate biopsy

A biopsy is a procedure in which a sample of body tissue is removed and then looked at under a microscope. A core needle biopsy is the main method used to diagnose prostate cancer. It is sometimes done under ultrasound guidance (TRUS) by a Urologist or Radiologist. For a few days after the procedure, you may feel some soreness in the area and will likely notice blood in your urine. You may also have some light bleeding from your rectum. Many men also see some blood in their semen, which can last for several weeks after the biopsy. Your biopsy samples will be sent to a pathology lab. There, a pathologist (a doctor who specialises in diagnosing disease in tissue samples) will see if there are cancer cells in your biopsy by looking at the samples under the microscope. Getting the results usually takes at least 1 to 3 days, but it can take longer. Even with many samples, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a "false negative" result. If your doctor still strongly suspects prostate cancer (due to a very high PSA level, for example) a repeat biopsy may be needed to help be sure.

Staging

The stage (extent) of a cancer is one of the most important factors in choosing treatment options and predicting a patient's outlook. If your prostate biopsy confirms that you have cancer, more tests may be done to find out how far it has spread within the prostate, to nearby tissues, or to other parts of the body. This process is called staging. Your doctor will use your Digital Rectal Exam (DRE) results, Prostate-Specific Antigen (PSA) level, and Gleason score to figure out how likely it is that your cancer has spread outside of the prostate. This information is used to decide which other tests (if any) need to be done.

Imaging tests used for prostate cancer staging

Not all men with prostate cancer need to have imaging tests, but for those who do, the following tests are sometimes used.

Radionuclide bone scan

When prostate cancer spreads to distant sites, it often goes to the bones first. (Even when prostate cancer spreads to the bone, it is still called prostate cancer, not bone cancer.) A bone scan can help show whether cancer has reached the bones. For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in damaged bone tissue throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton. Areas of bone damage appear as "hot spots" on your skeleton, that is, they attract the radioactivity. Hot spots may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern.

Magnetic Resonance Imaging (MRI)

This produces cross-sectional slices of the body like a CT scanner, but it can also show slices (views) from several angles. As with a CT scan, a contrast material might be injected, but this is done less often. MRI scans can be very helpful in looking at prostate cancer. They can produce a very clear picture of the prostate and show whether the cancer has spread outside the prostate into the seminal vesicles or the bladder. This information can be very important for your doctors in planning your treatment. To improve the accuracy of the MRI, many doctors will place a probe, called an endorectal coil, inside your rectum. This may stay in place for 30 to 45 minutes and may cause a little discomfort.

Computed Tomography (CT)

The CT scan (also known as a CAT scan) is a special kind of x-ray that gives detailed, cross sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into images of slices of the part of your body being studied.

Fine Needle Aspiration (FNA)

If your lymph nodes appear enlarged on an imaging study (CT or MRI) a specially trained radiologist may take a sample of cells from an enlarged lymph node by using a technique called Fine Needle Aspiration (FNA). To do this, the doctor uses the CT scan image to guide a long, thin needle through the skin in the lower abdomen and into an enlarged lymph node.

Prostate cancer treatment

Prostate cancer is a complex disease, and doctors may differ in their opinions regarding the best treatment options. You will want to weigh the benefits of each treatment against its possible outcomes, side effects, and risks.

Expectant management (watchful waiting)

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) may never need treatment for their prostate cancer.

Instead, their doctors may recommend an approach known as expectant management, or "watchful waiting." This approach involves close monitoring of the cancer without active treatment such as surgery or radiation therapy. It may be recommended if your cancer is not causing any symptoms, is expected to grow very slowly, and is small and contained within one area of the prostate. Watchful waiting is less likely to be a good option if you are young, healthy, and/or have a fast-growing cancer (for example, a high Gleason score).

Surgery

Radical prostatectomy is a surgery that attempts to cure prostate cancer. It is used most often if the cancer is not thought to have spread outside of the gland. In this operation, your surgeon is trying to cure you by removing the entire prostate gland plus some of the tissue around it, including the seminal vesicles.
The different type of surgeries that are normally done in cancer of the prostate are:
	Radical retropubic prostatectomy
	Radical perineal prostatectomy
	Laparoscopic Radical Prostatectomy (LRP)
	Robotic Radical Prostatectomy

Side-effects

The side-effects depend on the pre-procedure condition and also the extent of the disease. The possible side-effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). It should be noted that these side-effects are also possible with other forms of therapy. Urinary incontinence is not being able to control your urine or have leakage or dribbling.

Sterility

Radical prostatectomy cuts the connection between the testicles (where sperm are produced) and the urethra. This means that a man can no longer father a child by natural means. Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, you may want to speak with your doctor about "banking" your sperm before the operation.

Palliative procedure: Transurethral Resection of the Prostate
(TURP)

This operation is more commonly used to treat men with non cancerous enlargement of the prostate called Benign Prostatic Hyperplasia (BPH). When it is used for prostate cancer, it is palliative, which means it is done to relieve symptoms and not to cure it. This surgery may be used if you are having trouble urinating because of the cancer. During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine exits the bladder).

Radiation therapy

Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation is used as the initial treatment for cancer that is still confined within the prostate gland or that has only spread to nearby tissue. Cure rates for men with these types of cancers are much like those for men getting radical prostatectomy. Radiation is also used if the cancer is not completely removed or comes back (recurs) in the area of the prostate after surgery. If the disease is more advanced, radiation may be used to reduce the size of the tumor and to provide relief from present and possible future symptoms.

Two main types of radiation therapy are used:
External Beam Radiation and Brachytherapy (internal radiation).

External Beam Radiation Therapy (EBRT)

In EBRT, the radiation is focused on the prostate gland from a source outside your body. Before treatment starts, imaging studies such as MRIs, CT scans, or plain x-rays of the pelvis are done to find the exact location of your prostate gland.

You will usually be treated 5 days per week in an outpatient center over a period of 7 to 9 weeks. Each treatment lasts only a few minutes and is painless. Aside from being used as a treatment for early stage cancer, external beam radiation can also be used to help relieve bone pain when the cancer has spread to a specific area of bone. Standard (conventional) EBRT is used much less often than in the past. Newer techniques allow doctors to be more accurate in treating the prostate gland while reducing the radiation exposure to nearby healthy tissues. These techniques appear to offer better chances of increasing the success rate and reducing side-effects.

Three-Dimensional Conformal Radiation Therapy (3D-CRT)

3D-CRT uses special computers to precisely map the location of your prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage normal tissues. By aiming the radiation more accurately, doctors can reduce radiation damage to tissues near the prostate and cure more cancers by increasing the radiation dose to the prostate.

Intensity Modulated Radiation Therapy (IMRT)

IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that actually moves around the patient as it delivers radiation. In addition to shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to minimise the dose reaching the most sensitive normal tissues. This allows doctors to deliver an even higher dose to the cancer areas.

Image Gated Radiation Therapy (IGRT)

Tumours can move between treatment sessions due to changes in organ-filling. There could also be variations in patient's position during day to day treatment session set up. Now, a new technology has arrived to overcome this defect. The change in the position of tumour can be tracked with a CT scan mounted on LINAC (called Cone Beam CT), just before the treatment delivery and the appropriate corrections are made online. The imaging information from the "planned CT scan" done earlier is overlapped on this Cone Beam CT. This is called IGRT (Image Guided Radiotherapy). In some cases, tiny gold markers are implanted in or near the tumour to pinpoint it for IGRT.

Possible side-effects of External Beam Radiation Therapy

The numbers used to describe the possible side effects below relate to standard external radiation therapy, which is now used much less often than in the past. The risks of the newer treatment methods described above are likely to be lower.

Bowel problems
During and after treatment with External Beam Radiation Therapy, you may have diarrhea, sometimes with blood in the stool, rectal leakage, and an irritated large intestine. Most of these problems go away over time.

Bladder problems
You might find yourself needing to urinate more often, a burning sensation while urinating, and blood in your urine.

Urinary incontinence
This side effect is less common than after surgery.

Impotence
After several years, the impotence rate after radiation is about the same as that of surgery. It usually does not occur right after radiation therapy but slowly develops over a year or more.

Feeling tired
Radiation therapy may also cause fatigue that may not disappear until a few months after treatment stops.

Brachytherapy (internal radiation therapy)

HDR Brachytherapy
Hollow needles are placed through the perineum into the prostate. Soft nylon tubes (catheters) are placed in these needles. The needles are then removed but the catheters stay in place. Radioactive iridium-192 is then placed in the catheters, usually for 5 to 15 minutes. Generally, about 3 brief treatments are given, and the radioactive substance is removed each time. The treatments are usually given over a couple of days. After the last treatment the catheters are removed. For about a week following placement of the catheters, you may have some pain in the area between your scrotum and rectum, and your urine may be reddish-brown. These treatments are usually combined with external beam radiation given at a lower dose than if used by itself. The total dose of radiation is computed so that it is high enough to kill all the cancer cells. The advantage of this approach is that most of the radiation is concentrated in the prostate gland itself, sparing the urethra and the tissues around the prostate such as the nerves, bladder, and rectum. I-125 seeds are sometimes used for Brachytherapy which stay in the Prostate forever.

Possible risks and side effects of Brachytherapy:

Like external beam radiation, Brachytherapy can also cause impotence, urinary problems, and bowel problems.

Bowel problems
Significant long-term bowel problems (including burning and rectal pain and/or diarrhea) occur in less than 5% of patients.

Urinary problems
Severe urinary incontinence is not a common side effect. But frequent urination may persist in about 1 out of 3 patients who have brachytherapy. This is perhaps caused by irritation of the urethra, the tube that drains urine from the bladder. Rarely, this tube may actually close off (known as urethral stricture) and need to be opened with surgery.

Impotence
Problems with erections may be less likely to develop after brachytherapy than after other common forms of treatment.

Hormone (androgen deprivation) therapy

Hormone therapy is also called Androgen Deprivation Therapy (ADT) or Androgen Suppression Therapy. The goal is to reduce levels of the male hormones, called androgens, in the body. The main androgens are testosterone and Dihydrotestosterone (DHT). Androgens, produced mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels often makes prostate cancers shrink or grow more slowly. However, hormone therapy does not cure prostate cancer.
Hormone therapy may be used in several situations:
	If you are not able to have surgery or radiation or can't be cured by these treatments because the cancer has already spread beyond the prostate gland.
	If your cancer remains or comes back after treatment with surgery or radiation therapy.
	As an addition to radiation therapy as initial treatment if you are at high risk for cancer recurrence.
	Before surgery or radiation to try and shrink the cancer to make other treatments more effective.

Types of hormone therapy

There are several types of hormone therapy used to treat prostate cancer:

Orchiectomy (surgical castration)

Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where more than 90% of the androgens, mostly testosterone, are made. When this source is removed, most prostate cancers stop growing or shrink after some time. This is done as a simple outpatient procedure. It is probably the least expensive and simplest way to reduce androgen levels in the body. But unlike some of the other methods of lowering androgen levels, it is permanent.

Luteinising Hormone-Releasing Hormone (LHRH) analogs

These drugs lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called chemical castration because they lower androgen levels just as well as orchiectomy. LHRH analogs are injected and are given either monthly or every 3 months.

Anti-androgens

Anti-androgens block the body's ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, a small amount of androgens is still made by the adrenal glands. Drugs of this type, such as flutamide, bicalutamide, and nilutamide are taken daily as pills. Anti-androgens are not often used by themselves.

An anti-androgen may be added if treatment with orchiectomy or an LHRH analog is no longer working by itself. An anti-androgen is sometimes given for a few weeks when an LHRH analog is first started to prevent a tumor flare . Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called Combined Androgen Blockade (CAB).

Hormone-Refractory Prostate Cancer (HRPC)

Cancer that no longer responds to hormone therapy such as LHRH analogs or anti-androgens is considered hormone refractory, and can be hard to treat. Several chemotherapy drugs have been shown to reduce PSA levels and improve quality of life. Bisphosphonates appear to be helpful for many men whose cancer has spread to the bones. These drugs can reduce pain and even slow cancer growth in many cases.

Chemotherapy

Chemotherapy is sometimes used if prostate cancer has spread outside of the prostate gland and hormone therapy isn't working. It is not a standard treatment for early prostate cancer. Chemotherapy uses anti-cancer drugs injected into a vein or given by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment potentially useful for cancers that have spread (metastasized) to distant organs.

Possible side effects of Chemotherapy

Chemotherapy drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects. The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken.
These side effects may include:
	Hair loss
	Mouth sores
	Loss of appetite
	Nausea and vomiting
	Lowered resistance to infection (due to low white blood cell counts)
	Easy bruising or bleeding (due to low blood platelets)
	Fatigue (due to low red blood cells)
In addition, each chemotherapy drug may have its own unique side effects. The side effects of chemotherapy are usually short-term and go away once treatment is finished. There is help for many of these side effects. For example, drugs can be given to prevent or reduce nausea and vomiting. Other drugs can be given to boost blood cell counts.

Pain management

When properly prescribed, pain medicines (ranging from aspirin to opioids) are very effective. You may worry about addiction or dependence with opioids, but this is almost never a problem if the drug is being used as directed to treat cancer pain. Symptoms such as drowsiness and constipation are possible but can usually be treated by changing the dose or by adding other medicines.

Bisphosphonates

Bisphosphonates are a group of drugs that can help relieve bone pain caused by cancer that has spread (metastasized). These drugs may also slow the growth of the metastases and prevent fractures. Bisphosphonates may have the added benefit of strengthening bones in men who are also receiving hormone therapy.

External radiation therapy

Radiation therapy can help reduce bone pain, especially if the pain is limited to one or only a few areas of bone. Radiation can be aimed at tumours on the spine, which can help relieve pressure on the spinal cord in some cases. Radiation therapy may also help relieve other symptoms by shrinking tumors in other parts of the body.

Radio pharmaceuticals

Strontium-89 and Samarium-153 are drugs that contain radioactive elements. They are injected into a vein and collect in bones. Once there, the radiation they give off kills the cancer cells and relieves some of the pain caused by bone metastases. About 80% of prostate cancer patients with painful bone metastases are helped by this treatment. These drugs are used to treat bone pain caused by metastatic prostate cancer -- they are not for early stage prostate cancer. These drugs are especially helpful when prostate cancer has spread to many bones, since external beam radiation would need to be aimed at each affected bone. In some cases, one of these drugs will be used together with external beam radiation aimed at the most painful bone metastases.

Follow-up care

After treatment for prostate cancer, your doctor will want to watch you carefully, checking to see if your cancer recurs or spreads further. Your doctor will also outline a follow-up plan. This plan usually includes regular doctor visits, PSA blood tests, and digital rectal exams, which will likely begin within a few months of finishing treatment. Most doctors recommend PSA tests about 2-6 months for the first 5 years after treatment, and at least yearly after that. Bone scans or other imaging tests may also be done, depending on your medical situation. Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be permanent. Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

Motto of Max Cancer Care

At Max Cancer Centre, we are committed to recuperating our patients as soon as possible. Our dedicated team of leading Oncologists provides the most advanced cancer treatments using cutting edge technology, based on International Standards. Cancer Care requires medical professionals from different specialties to collectively execute an individualised patient care plan for best results. We firmly believe in delivering quality care, support and re-assurance to our patients.

We believe that each patient and his/her disease is unique, hence our team of Oncology experts customise a 'personalised treatment plan' based on the discussions in Tumour Board conferences. We constantly review and improve our protocols and encourage the participation of our patients as well as care givers to understand the disease and its treatment process.

"Back to Life" is how we like to define the intent behind our services at Max Cancer Centre and we prefer to call our program "Max Cancer Care" because we strongly believe that caring for the needs of the patients and care givers is more important than the medical services they avail.

Max Healthcare provides holistic cancer care that includes

	A consolidated review of your case from experts in Surgical Oncology, Radiation Oncology, Medical Oncology and the concerned speciality. This way, hidden costs and multiple inter-departmental visits are curtailed.
	Adherence to the latest international cancer treatment protocols.
	Superior Cancer treatment technology : Max Healthcare is the first facility in Northern India to acquire Novalis Tx for IMRT/IGRT, Radiosurgery, SRS/SRT. The centre is also equipped with facilities for Brachytherapy.
	Complete Cancer Care: Right from cancer screening, early detection, multi-disciplinary treatment to rehabilitation.
	A wider range of medical resources to draw from, with our multi-super speciality back-ups.
	Unique synergy with Neurosciences for Brain Tumours: We are the first cancer care institution in Asia to have the intraoperative MRI BrainSUITETM integrated with Novalis Tx Radiosurgery, which gives us a unique advantage in treating cancers related to the brain.
	Tumour Board: At Max Cancer Centre, a team of our experts from Surgical Oncology, Radiation Oncology, Medical Oncology, Pathology, Imaging and related disciplines come together in the Tumour Board meetings to discuss various cases and form a customised/ joint decision on the treatment plan.
This is only for the purpose of information and can not be substituted for medical advice In case of a query, discuss it with your doctor.