Author: Dr Joseph Sequeira MS (Onco Surgery)
The incidence of Cancer is rising with every passing day. We are all witness to the different presentations of these cancers in various stages from Stage 1 to Stage 4. Till today, 70% of our population reside in rural areas where Medical facilities are dismal. This leads to the exodus of patients to semi-urban and urban areas in the hope of cure for this dreaded disease. However, the overloaded Government Tertiary Cancer Centres are unable to accommodate the added influx of these patients and their relatives leading to never ending waiting lists. The only options available are to opt for treatment in a private hospital where the costs are exorbitant causing financial bankruptcy to the family or wait endlessly. During the waiting period the patients and their relatives are also drained physically mentally and financially but more importantly, the disease progresses sometimes beyond cure.
Can WE reverse this situation at least marginally?
The Sister Doctors Forum of India has more than one thousand members working in the remotest areas of our country. However they are dedicated to the medically underserved brethren and most importantly well trained and experienced. It is my humble belief that if the Sister Doctors could be imparted knowledge on some basic aspects of Cancer management which could be used in a rural hospital, the hardships to the patients and their relatives could be decreased.
CANCER SCREENING The main problem that we face in Cancer Cure is that majority of patients at presentation are in in an advanced stage of the disease. Though the trend is slowly being reversed in urban areas, the situation in rural areas is still dismal with no signs of improvement. The key to early detection is Cancer screening ideally of the entire population or at least high risk groups. This must be done on a regular basis at least once a year and any pre malignant condition or suspected malignancy must be rigourously followed up. Since targeting all Cancers will be cumbersome and not cost effective, I would suggest screening for the most common cancers occurring in males and females which would cover 80% of the cancer burden. For males, examination of head and neck, per rectal, Chest Xray +/- PSA (above 50) would cover head and neck, rectal, lung and prostrate cancers. For females, examination of head and neck, breasts, per rectal, per vaginal, pap smear, Chest Xray, +/- CA-125 would cover head and neck, breast, rectal, cervix, lung and ovary.
DIAGNOSIS Once Cancer is suspected the focus is on a complete work up to prove malignancy. The initial investigations are mainly to locate the primary from where a biopsy could be taken if possible. For this, basic investigations like Chest Xray, Sonomammography, CT scans and Tumour Markers would suffice in guiding the location for a FNAC, TRU-CUT biopsy or fluid cytology which could be performed either directly or USG or CT guided. The specimen may be sent to a central lab or tertiary centre for expert opinion.
STAGING Proven malignancy ideally requires a metastatic work up. Simple investigations like Xrays , USG +/- CT scans can usually detect gross metastatic disease in a majority of cases. Tissue diagnosis and metastatic work up helps in staging the disease, which in turn helps in prognosis with its treatment options. This is where the most important and difficult step lies and that is counseling the patient and the relatives for further treatment at the rural hospital or reference to a tertiary Cancer centre.
MANAGEMENT Depending on the infrastructure available some Surgeries can definitely be performed in rural hospitals by trained specialists. However the surgeon must be confident of performing the surgeries as per the Oncological principles independently with minimal blood loss and minimal complications. Having set up and performed Cancer surgeries in rural hospitals for the past 22 years I would say that the following Curative surgeries can be performed in rural hospitals with adequate infrastructure by experts. Breast Radical Mastectomies, Radical Hysterectomies / Wertheims Hysterectomies, Gastrectomies / Colectomies, Oral surgeries including Commandos and laryngectomies. In addition almost all palliative surgeries can be performed like Tracheostomy, Feeding gastrostomy, jejunostomy, Intestinal bypass surgeries, Colostomies etc.
Advanced Metastatic disease patients and their relatives require extensive Counselling about the poor prognosis and the implications of shifting to a tertiary cancer centre, especially the financial aspect and deterioration of the general condition of the patient. The relatives could be given an option of taking an opinion at a Cancer hospital of their choice with all the reports available and if the treatment options are better and beneficial, then the patient could be shifted to a higher centre.
CHEMOTHERAPY can definitely be given in a rural primary care hospital. A good venous access and prevention of extravasation are are the basic nursing requirements. Choose a larger IV cannula in a moderate sized vein. Today PICC and Chemoports are a fashion though frightfully expensive. Knowledge of the common side effects of the various Chemotherapeutic agents is essential, though drug allergies would be mostly encountered. Remember that adverse reactions would even occur in a tertiary hospital set up and anticipation and emergency resuscitation is the only expected treatment. Though a Chemotherapy protocol given by an Oncologist would be ideal I would always suggest you to check the protocols to rule out printing errors especially in dosage.
PALLIATIVE CARE is the backbone of Cancer management since the majority of cases present in a late stage i.e. Advanced Metastatic Stage IV disease. Basic divisions include PAIN MANAGEMENT based on the WHO based step ladder choice of drugs. Titrate drugs dosage and frequency to the optimum pain free state. Choose drugs that are easily available. WOUND CARE Suitable dressings to prevent bleeding, absorbent dressing for copious discharge so as to keep the patient comfortable.
NUTRITION Enteral feeds are the most preferred route, sometimes with the help of tube feeds. Parenteral route can be used in required cases (IV fluids, TPN)
SYMPTOMATIC TREATMENT for vomiting, constipation, cough, breathlessness etc.
INVASIVE TECHNIQUES Ascitic tapping, Pleural tapping, Pleurodesis, etc.
PALLIATIVE SURGERIES for stridor eg. Tracheostomy and pathological fracture of bones.
FOLLOW UP PET – CT scan is the best investigation available to assess metastatic, residual and recurrent disease and hence widely used in follow up. However, its limited availability and high cost prevents its widespread use. Hence a good clinical examination and basic investigations can give a rough idea and then costlier investigations can be suggested in case of strong suspicion. Blood tests include CBC / LFT / RFT / LDH and Tumour Markers (CEA, CA-125, AFP, B HCG, CA 15-3, CA 19-9). Other tests include Xrays (Chest, Spine, Skull, Abdomen) Sonography (Neck, Chest, Breasts, Axilla, Abdomen, Pelvis), Mammography, CT Scans, MRI. Adequate information can be obtained from basic scans reported by a dedicated Radiologist.
CONCLUSION Adopting few if not all the above Management techniques in Cancer by our Extremely Efficient, Dedicated and Experienced Sister Doctors will go a long way to improve Cancer Survival and Reduce Suffering.