'I am told to have cancer - What are my chances



"Doc, I am told to have cancer – I quit smoking years ago! What are my chances? What are my options? How soon should I decide on my options?"

Modified and Created by NAZARIO A. MACALINTAL JR., MD,FPCP, FPCCP*

for MMC IM JCI requirements vApril2009

Classically, a lung cancer patient has a heavy smoking history, either active or have quit over several years ago. One of the puzzles, or regrets that smokers have upon learning of this life-threatening illness - is "Why did I develop this when I have quit over 10 years ago?"

A common belief is that lung malignancy risk halts when the smoking habit stops. First of all, this is not correct, because the risk persists up to one-and-a-half decade after quitting, although it fades through the years. Getting malignancy is partly dependent on risk exposure , be it from habits like cigarette smoking or from occupational exposure to cancer-inducing substances like asbestos.

There are smokers though who do not get lung malignancies despite heavy smoking history and this subgroup ‘resistant’ to cancer risk may be explained by their genetic predisposition, i.e., oncogenes or the lack of stimulating it. Somehow, it looked like we all have these genetic predisposition, which if unlocked, paves the way for the development of a malignancy, be it pulmonary or otherwise.

The question of "What are my chances of survival?" is always not easy to answer to a patient who is suddenly faced with the threat of expiring lease of life. More often than not, it is an issue that has to be settled collectively with the immediate relatives, the spouse and children most specially. Some patients are ready to accept the reality and meet problems head-on - and wanted to know his/her options right away… some prefer not to know, although you can be certain before they pass away they will confirm with you he or she has it. By this time, you already know they are ready to accept it, and had done so actually.

Basically, lung malignancies can be classified into four categories: the very aggressive one, which rapidly spreads by blood, then the other one which spreads by creeping mechanism, and tends to spread slower, and the other two which are sort of in-betweens of the first two categories. To the first category belongs what is known as the small cell cancer. This type, once discovered, generally makes any surgery option out of the question because in more than 70% of cases, this has spread to other organs during the time of diagnosis - even if the patient does not feel anything. In the second category belongs the Epidermoid Lung cancer, which is a little ‘lazier’ in terms of behavior, you-see-it-now,-you-check-it-in-6-months, -it-seemed-like-it-has-hardly-grown-in-size sort of thing.

It must be understood however that even within this general category, it can still be subdivided further into which is more ‘behaved’ and those which do not. And so classifications like poorly differentiated and well-differentiated or moderately differentiated will always come in our patient's histopath or biopsy reports. For the so-called "well-differentiated ones", this is like a group of creatures which should looked the same and are alike, and the "poorly differentiated ones" can be analogous to a group of supposedly similar creatures but turns out grossly different from each other. The poorer the differentiation, the more aggressive the cancer becomes, and the more difficult to handle --> consequently the worse the prognosis.

And so comes again that difficult patient question: "What are my chances, Doc?" It is shown that the over the last 25 years, the 5-year general survival rate for lung cancer hovers around only 17 percent, with the attrition rate being highest in the first 2 years. It is very important that before this gruesome reality is conveyed to the patient (or to the relative), the physician should exert utmost effort to determine the readiness to accept the fact that he/she is sick, and has limited time left, in fact, very limited.

It is also important to make patient realize that some people do better than the general trend - from 6 months to about 2 years. And on the other end of the spectrum, some perform worse than the general pattern, i.e., despite various treatment measures like surgery, medical therapy, or radiation treatment.

"What if surgery is considered? How soon can it be done?"

Surgery for lung cancer is considered if the disease is so-called Stage III-A or better. In simpler terms, the disease should not show evidence of spread to the other lung or other organs outside chest cage, to the big vessels of the heart or the bone or to the chest cavity. To pursue these possibilities, several work-ups need to be done and which will include the following: [a] Complete blood count (CBC) with quantitative platelet studies , [b] Blood chemistry which will at least include liver and bone enzyme tests, [c] Chest CT Scan preferably with contrast studies, [d] Whole Body Bone Scan, [e] Brain MRI or CT SCan, [f] MRI or CT Scan of the liver, kidney and adrenals. Any evidence of spread from these studies makes surgery generally out of the question, although in more specialized cancer centers, more aggressive approaches are tried despite evidences of spread.

The cost of these work-ups should be anticipated and explained, because there are other work-ups that needs to be done before surgery is pursued and basically it revolves around the question of how much of the lung would remain if the affected lung is removed. The pulmonary clearance pre-surgery will determine if after surgery, the patient will end up being dependent on a mechanical respirator - pulmonary cripple that is. If the risk is high, the surgery may not be pursued and other remaining treatment options be considered, like radiotherapy or chemotherapy, depending on cancer specialist's assessment.

Radiotherapy is not expensive and can be rendered on an out-patient basis. Complications are not frequent but when it occurs, it can also be equally devastating, like scarring in the spinal cord at the level of chest cage, or scarring of the esophagus. Not all lung cancers though respond to radiation treatment, as is also the case in using chemotherapy.

Another option is what they called RFA , or Radiofrequency Ablation. It is a procedure whereby those who could not undergo surgery or simply does dos not want it can opt to have the tumor, assuming it has not spread yet and it is not that big yet, dissolved by , as the name implies, radiofrequency. Just like any other treatment options for malignancies, it is not without complications, mild and not mild but manageable, for example, blood in sputum, chest pain or sometimes lung collapse.

Chemotherapy is used for those cancers that multiply rapidly and are tried in different combinations of medications each hitting the cancer cells via different mechanisms in different cell cycles. This treatment option is more expensive though and may not be available to all who needed it, but can give long remissions depending on the cancer's responsiveness to it. In the recent years, chemotherapy medications in tablet forms have been available!!

Over the past recent years, there are other attempts to fight cancer using genetic engineering whereby microbes are “designed to kill cancer cells and spare normal ones, something chemotherapy does not do in general. It is not yet available , as I understand, even in most tertiary hospitals.

… Fighting cancer is a difficult battle - the odds are often not in the favor of those who suffer from it. Early detection while giving higher chances of surgical cure are often not happening since most are found in more advanced stages. Whenever possible, all treatment options should be considered.

Lastly, while medical expertise can provide hope for extension of life, assisting patients in seeking moral and spiritual supports are something that should not be missed. Incidentally, there is a locally launched magazine called “Big C” for cancer patients or relatives with cancer and has been providing outstanding support to those who need it.

Modified and Created by NAZARIO A. MACALINTAL JR., MD,FPCP, FPCCP*

for MMC IM JCI requirements vApril2009

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