Principles and Management of Cancer Tejinder Kataria, Hemant Singhal , Dinesh Chand Doval
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1Principles and Management of CANCER2
3Principles and Management of CANCER
Tejinder Kataria MD DNB CCST FIMSA Chairperson Division of Radiation Oncology Medanta Cancer Institute Medanta—The Medicity, Sector-38, Gurgaon Haryana, India Hemant Singhal FRCSED FRCSC MBA Consultant Breast Surgeon The Harley Street Breast Clinic Platinum Medical Centre, Wellington Hospital, UK Dinesh Chand Doval MBBS MD Director Medical Oncology and Research Rajiv Gandhi Cancer Institute and Research Centre Rohini, New Delhi, India Foreword Karol Sikora
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Principles and Management of Cancer
First Edition: 2016
9789351529712
Printed at
5Dedicated to
Our patients who teach us to perform to the best of our abilities because life matters and to our young physicians, who question our beliefs and make us tread the ever-widening frontiers of science
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7Contributors
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11Foreword
The optimal treatment of cancer in every economic environment requires remarkable teamwork. The three main therapeutic modalities—surgery, radiotherapy, and chemotherapy require a seamless integrated approach alongside the equally important psychosocial support of an often distressed human being.
This excellent text is put together by a series of eminent Indian oncologists and it is skillfully edited by Dr Tejinder Kataria from Medanta, The—Medicity, Haryana, India. It summarizes beautifully the current team approach to all major cancers. The epidemiological background to a plethora of malignant diseases is considered, which is followed by the common diagnostic and staging pathways currently used. It is both didactic and pragmatic, and hence provides an excellent basis for trainees in oncology to build-up their knowledge base quickly whilst at the same time learning through their clinical experiences. The text will come to life as the human stories are added to the factual analysis in the book.
It will be particularly useful to those taking training in radiation oncology, but cancer surgeons and medical oncologists will find much of interest too. It teaches a strategy for each tumor type rather than a detailed recipe which can only be concocted when the equipment and resources of a specific treatment center have been identified. The chapters are comprehensive with numerous examples of best practice scattered in-between excellent clinical pathway summaries. Even complex management decisions are explained extremely clearly. The concept of risk of recurrence stratification to determine optimal radiotherapy and chemotherapy is described very clearly for prostate and gynecological cancers in their respective chapters. Maybe one day it will all be carried out by computer algorithm but for now it is clinical judgment that needs to be an acquired skill.
The cost of cancer care has huge effects on the poorer populations around our globe. Some of the new molecular targeted therapies for cancer cost more for one year's supply than many citizens of the world will earn in their whole lifetime. The insertion of cost into the equation to decide on the optimal care for an individual is hugely challenging for clinicians—especially those trained in an era where governments took care of costs. Cancer decisions in the past were based on medical need and not ability to pay. But there is no going back now. This is especially important in low resource environments.
It is clear from these well-thought-out chapters that world class cancer care is being delivered in India. But as in all countries, rich and poor alike, there is a huge variation in the quality of treatment accessed by different patients. Improving the bottom of the pyramid is far more important than the top and this applies throughout the cancer pathway from screening, diagnosis, treatment and palliative care. Seeking to improve the average will have the greatest gain for the most people. This is a task for the educationalist, and Dr Tejinder Kataria and her team have made an exceptionally good start. This book deserves to become a standard text to be found in every resident's bag. Maybe the next edition will be electronic with yearly updates in areas where approaches are rapidly changing. It deserves to become one of Asia's few standard oncology texts.
Professor Karol Sikora MA FRCR FRCP PhD
Chief Medical Officer
Cancer Partners UK and Dean
University of Buckingham Medical School
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13Preface
Developing countries are facing an ever-increasing incidence of cancer and it is expected that they are going to have a dual burden of infection-related cancers (cervix, liver and stomach) as well as lifestyle-related cancers (lung, colon, breast). Cancer is becoming a major health concern in India, with the number of new cancers projected to double in the next two decades; (Globacon–2012), 1.1 million new cases of cancer are diagnosed every year in a population of 1.2 billion with about 60,000 deaths per year.
An accurate correct diagnosis of cancer is essential for adequate and effective treatment as each disease requires a specific treatment. A patient may need one or more modalities of surgery, radiation, chemotherapy, targeted therapy or immuno- therapy. The primary goal of therapy is to cure cancer with minimum toxicity and/or palliate with a good quality of life in advanced disease.
The Human Genome project and subsequent gene mapping, gene sequencing and next generation sequencing have changed the way of cancer diagnosis and treatment, and prognosis of the disease is perceived today. Till the time we can identify and stop the switch that makes cancer cells immortal; we have to approach and treat this malady with an integrated approach. The world has shrunk into a global village with the developments in telecom, computation, analytics, and results of research are available worldwide within a short span of time. Drugs, techniques, equipment, and training thereof, is within the reach of many as compared to a few, till a decade ago. This has revolutionized the way we treat any disease, including cancers, as is evident from the body of work presented in this book.
The book Principles and Management of Cancer is an effort to approach cancers site-wise and learn the alphabet of treating the various stages of different cancers using the present-day diagnostic aids and treatment modalities. The first few chapters give an insight on the development of technical nature in the last 100 years, the basics of diet, and emergencies encountered amongst the cancer patients. The site specialized treatments constitute the main body of the book and include stage specific-wise assessment to manage a patient with the best practices of three main therapeutic modalities, namely, viz. surgical, radiation and medical oncology. The final chapters introduce the concepts of Quality assurance, Drug discovery and Clinical trials.
The endeavor of the authors has been to present the standard of care as practised for various cancers and show the case work being done by them in their respective areas. We hope the book is received in the spirit it is written, i.e. to expand the reach of a textbook for cancer to students, teachers and practitioners in developing countries as well as low and middle income countries. We would like to invite the readers to give their feedback to include/exclude any sections, so that the future editions are more inclusive rather than exclusive.
Tejinder Kataria
Hemant Singhal
Dinesh Chand Doval
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15Acknowledgments
With the deepest gratitude I wish to thank everyone who has touched my life, inspired and guided me through their presence. First and foremost, I am grateful to Dr Naresh Trehan for setting up a world class hospital in Gurgaon, Haryana, India, and giving me an opportunity to be a part of its cancer wing. His vision and insight in medicine at large and deep involvement in planning and execution of the project is unparalleled. The permission to use the pictorial matter and illustrations from Medanta Cancer Institute and Medanta—the Medicity was given by him instantaneously, when I approached him with the proposal to write a book on Principles and Management of Cancer.
I have been fortunate in having had excellent teachers during my postgraduation at Postgraduate Institute, Chandigarh, India, BD Gupta and S Ayyagiri were responsible for inculcating a sense of commitment to patient care and coordinating with various surgical subjects to understand the multimodality treatment of cancer. Both of them taught me that I can learn a new way of thinking and perform complex processes required in managing cancer patients not only from doctors but also from our Medical Physicists, Radiotherapy Technologists, Nurses, Pathologists, Surgeons and of course the world of Books ! that is fast disappearing in the electronic era. This book pays a tribute to their dedication to make me learn the Science of Radiation Therapy and develop the Art of Patient Care.
The tutelage of Professor Joslin, Dr DV Ash and Dr Bryan Dixon from UK for Brachytherapy and Radiobiology, formed the alphabet for the syntax of conformal treatments later in life for me. I shall be forever indebted to them for their excellent tutorial skills. Dr Holger Hof at DKFZ, Heidelberg, Germany, taught me the basics of Intensity Modulated Radiotherapy and Professor Frank Lohr at Mannheim, Germany, Image Guided and Volumetric Modulated Radiotherapy. I am obliged to all my teachers to have helped inculcate a sense of wonder and awe, that is brought about by understanding the newer concepts of science.
I am thankful to Dr Hemant Singhal and Dr DC Doval for agreeing to be the Co-Editors to the first issue. Dr Kuldeep Sharma, Dr Vikash Kumar, Dr Shyam Singh Bisht, Dr Deepak Gupta, Dr Trinanjan Basu, Dr Ashu Abhishek, Dr Anurita Srivastava, Dr Govardhan and Dr Manoj Tayal have been my co-authors on different chapters without compromising their clinical duties.
I would like to acknowledge and express my gratitude to Dr AK Dewan, Dr Ajaypal Sandhu, Dr Sushil Beriwal, Dr Kanchan Kaur, Dr Kumud Kumar Handa, Dr Sandeep Jain, Mr Karthick KP, Dr Sandeep Batra and Dr Kushal Narang for their contribution to their areas of expertise. Dr Ishani Mohapatra gave us the histopathology microphotographs and I thank her from the core of my heart.
I am grateful to Dr Rajesh Vashistha, Secretary General AROI, for agreeing to release the book at annual AROICON this year and to Dr Shaleen Kumar, Organising Secretary, to endorse his decision.
This book would not have been possible without—M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, their technical support, guidance, manuscript evaluation and patience. I am thankful to Mr Tarun Duneja (Director-Publishing) and Ms Shivangi Pramanik for bearing with us and helping us complete the book.
I would like to thank Mr Reena George and Mr Dinesh Kumar for their secretarial help and collating the text to the photographs.
Last but not least, I am grateful to Rajiv Kataria, my husband and my daughter Shruti Kataria, for their unstinted support during the last 2 years and not begrudging my time away from them, in this academic pursuit.
Tejinder Kataria