Dr Chetan Deshmukh

Friday, 26 July 2013 16:46

Got Diagnosed with Cancer

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It is natural for a patient to feel devastated after being diagnosed with cancer. Most patients are too numbed by the pain of this diagnosis to enter into a prolonged question-and-answer session with their doctors. Often, the relatives need to take on the responsibility to get the necessary information before proceeding with treatment. Armed with information, patients can make better decisions about their treatment.

Most people complain that their doctors are too busy to have a sit-down discussion with them and consequently, have little information about their disease. It is true that the doctors may be busy but they are also faced with a dilemma- how much information should be given to the patient/relatives and how? Explain it in purely technical terms and the medical jargon is lost on the patient. Oversimplifying the matter may make it worse with patients not grasping the gravity of the situation.   How much information is then required? Most patients themselves have very few questions.

  1.  Why did it happen and to me? There are several causes and risk factors about different cancers, but it may not always be possible to pin-point the exact cause of an individual’s cancer. Eg: It is a well-known fact that tobacco chewing can cause oral cancer. However, many patients who have never chewed tobacco in their entire life may also develop oral cancer. This only underscores the fact that there are several other causes and risk factors yet to be discovered.
  2. Will I be completely cured? It is but natural for a patient to be worried about his disease. The concept of cure, however, can be different for the patient and doctor. For a patient, cure often means complete resolution of the disease on CT/MRI scans/any other imaging. For the doctor, cure means complete resolution of the disease and staying that way! If the disease does not rear its ugly head for a sizeable period (which may be different for different cancers), only then will the doctor proclaim it as cured.
  3. What will be the cost of treatment?  This is a very important question as the cost of treatment, investigations, surgeries and hospitalization is rising. Novel, more effective modalities of treatment are also very expensive. Some patients are covered by government schemes or private insurance, but many are not. Also, nonmedical expenses like transport and food and loss of wages of the patient and/or attendant during hospitalization are not taken into account  by any insurance.  Patients with unlimited resources can opt for the high-end therapies but those with a budget need to discuss the most cost-effective options with their doctor.
  4. What should I eat/not eat? No counseling session is complete without a lengthy discussion on diet. In a country like ours, enriched with different cuisines and their fusions, food becomes a very important part of our lives. Diet and restrictions during cancer treatment is a separate topic in itself.  It would suffice to say for the time-being that there are usually no major restrictions related to diet (except for those with preexisting medical problems like Diabetes, Hypertension etc) during cancer treatment.

If the patient is not in a right frame of mind to ask questions and discuss issues pertaining to his health in detail, one/more of his relatives need to take up the responsibility and sort out all the problems before initiation of treatment. It needs to be understood that cancer treatment is often taxing, expensive and lengthy. It is not possible to backtrack and start afresh. So, the first step needs to be the correct one.  In addition to the questions above, patients/relatives need to discuss a few more things.

  1. What is patient’s diagnosis: The diagnosis of cancer begins with a pathology report. A biopsy (removal of a small piece from the cancerous growth) or a fine needle aspiration cytology (FNAC) examination is performed to find out the type of cancer. In the pathology reports, sentences like `Suspicious of malignancy’, `Positive for malignancy’ are not sufficient to draw meaningful conclusions or initiate treatment. For the patient, a positive report means the diagnosis is confirmed, which is true to a certain extent. But such reports do not tell us the type of cancer, its grade (which, incidentally is different from stage and tells us about the tumour aggressiveness) or differentiation and the possible tissue of origin. A diagnosis needs all of these. An example of a formal diagnosis would be ` Well differentiated  squamous cell carcinoma of the buccal mucosa’. In select cases additional tests like Immunohistochemistry may be ordered by the pathologist to ascertain the exact type of cancer.
  2. What is the stage of cancer: Once the presence of cancer has been confirmed by a pathology report, one needs to find out the extent of spread of cancer. This is called `staging’ a cancer. Stage of cancer is extremely important in deciding its treatment and the outcome of treatment. Radiological tests like CT scans, MRI scans or PETCT scans may be done to confirm the stage. Patients with localized cancer (early stage disease- stage I-II) fare better than the more advanced ones.
  3. What is the best modality for treatment? Surgery, Chemotherapy and Radiotherapy are the 3 standard modalities of cancer treatment. Their sequence is decided by doctors based on the stage and type of cancer. Eg: The best modality for stage I breast cancer is surgery followed systemic treatment (chemotherapy or hormonal therapy) and /or radiotherapy if indicated. In case of a stage III disease of breast cancer, the sequence may be altered to chemotherapy first followed by surgery and some more chemotherapy and radiotherapy. The treating doctor is the best judge of the sequence of treatment. Patients can voice their choice but scientific principles take precedence over everything else. Eg: A patient has been diagnosed with early stage oral cancer. He/She may not be keen on surgery but the choice of treatment remains surgery. The doctor keeps `adequate cancer control’ as his priority and tries to accommodate the patient’s choice. Cancer control can never be compromised merely to satisfy a patient’s wish.  In another situation, a patient may present with enlarged lymph nodes in the neck, biopsy of which reveals a Non-hodgkin’s lymphoma. The standard therapy for this illness is chemotherapy. A patient may feel that surgical removal of the nodes will save him the trouble of chemotherapy, but sadly, that’s not the case. So, even if surgery is easily possible, such a patient will be counseled against surgery.
  4. What are the alternate options ? Sometimes, the modality suggested by the doctor may not be agreed upon by the patient for one or the other reason. In this situation, it is best to discuss with the treating doctor about availability of other options. If the options do not compromise optimal cancer control, your doctor may suggest you one or more of these options. Eg: A lady diagnosed with breast cancer has been advised complete removal of the breast, which she does not want.  Alternatively, she may be offered chemotherapy to shrink the size of the tumour and then re-examined for possibility of a breast saving surgery.
  5. What additional tests are required ? Apart from staging investigations, doctors may suggest tests to assess your physical fitness and ability to undergo the said treatment. These include Liver function, kidney function tests, blood counts, 2-D-Echocardiography. Patients with medical illnesses like diabetes, heart disease etc may require additional tests and concerned specialists need to consulted prior to starting treatment. 
  6. How will the treatment be given ? It is widely believed that chemotherapy is a single, very painful injection which is given once every 21 days for 6 courses.  It should be noted that some of the chemotherapy regimes are on a weekly basis going on for as many as 24 courses. The pain during chemotherapy comes only during the first venepuncture while starting an intravenous line. We also have oral chemotherapy drugs. A lot of fears of chemotherapy can be allayed by a single trip to the chemotherapy Day-care unit.
  7. What will be the after-effects of treatment? Most patients fear chemotherapy due to its side-effects. It is true that chemotherapy can cause several symptoms ranging from mild weakness to severe cardiac, renal, liver or blood related problems. But is highly unlikely that an individual patient is going to suffer from all of them. In fact they may suffer from none of these or some very mild effects. It is advisable to be in the know about the possible side-effects of chemotherapy. Some of the effects may occur during actual chemotherapy infusion, some after a few days and some may occur after few months or years.

A thorough pretreatment discussion reduces post treatment confusion and panic. The lame excuse about `not having enough time’ should not be given and accepted.

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Dr Chetan Deshmukh Consulting at

1

Pune

1. Deshmukh Clinic & Research Center,
2. Deenanath Mangeshkar Hospital,
3. Ruby Hall Clinic, Pune, Maharashtra, India.
2

Kolhapur

Kolhapur Cancer Center, Gokul-Shirgaon MIDC, Kolhapur-Kagal Road, Kolhapur. Maharashtra, India.
3

Miraj

Mahatma Gandhi Cancer Hospital, Near Gulabrao Patil Medical College, Miraj, Maharashtra, India.