About cancer

Signs worth showing a doctor

Most of these turn out to be something else entirely. That is precisely why they are worth checking rather than watching. See a doctor if any of them lasts more than two or three weeks:

• A lump or thickening anywhere: breast, neck, armpit, testicle or elsewhere
• A sore, ulcer or white or red patch in the mouth that does not heal
• A cough or hoarseness that will not settle, or coughing up blood
• Difficulty swallowing, or persistent indigestion
• A change in bowel or bladder habit that lasts
• Bleeding from anywhere it should not come from, including between periods, after menopause, or after intercourse
• A mole that changes shape, colour or size, or begins to itch or bleed
• Weight loss you did not intend, unexplained fever, or drenching night sweats
• Tiredness that rest does not fix

What raises the risk

Risk is not fate. Many people with several of these never develop cancer, and some people with none of them do. What follows raises the odds, and most of it can be changed:

• Tobacco in every form: smoked, chewed, gutka, khaini and the rest. It is the single largest preventable cause of cancer in India, and mouth and throat cancers here are closely tied to it
• Alcohol, which raises the risk of cancers of the mouth, throat, oesophagus, liver, bowel and breast, and multiplies the risk when combined with tobacco
• Diet and weight: being overweight over many years is linked to several cancers
• Certain long-standing infections: human papillomavirus (cervical and some mouth and throat cancers), hepatitis B and C (liver), Helicobacter pylori (stomach), Epstein–Barr virus, and HIV through a weakened immune system
• Sunlight and ultraviolet exposure, for skin cancers
• Radiation and workplace exposure to asbestos, certain dyes, dusts and chemicals
• Inherited faults in genes, which account for roughly five to ten in every hundred cancers. Most cancers are not inherited
• Age. Most cancers are diagnosed later in life, simply because damage accumulates

The main families of cancer

Cancers are grouped by the kind of cell they begin in, which is part of what decides how they behave and how they are treated:

• Carcinoma begins in the cells lining organs and skin. Most cancers are carcinomas, including breast, lung, bowel, cervix and prostate
• Sarcoma begins in bone, muscle, fat, cartilage or other connective tissue
• Leukaemia begins in the blood-forming tissue of the bone marrow, so it does not usually form a lump
• Lymphoma begins in the lymphatic system, the network that carries immune cells
• Myeloma begins in the plasma cells of the bone marrow
• Melanoma begins in the pigment-making cells of the skin
• Tumours of the brain and spinal cord, which are grouped separately because of where they sit

What lowers the risk

• Stop tobacco in every form. Nothing else on this list comes close
• Cut down or stop alcohol
• Keep to a reasonable weight, eat more fruit, vegetables and whole grains, and less processed and red meat
• Move regularly. Most guidance suggests around thirty minutes of activity on most days
• Vaccination genuinely prevents some cancers: HPV vaccine against cervical cancer, hepatitis B vaccine against liver cancer
• Cover up in strong sun
• Follow safety rules where you work if you handle dust, fumes or chemicals

Screening: looking before there are symptoms

Screening tests are for people who feel perfectly well, and they exist because some cancers are curable when caught before they announce themselves. Which ones apply to you depends on your age, sex and family history, so ask your doctor what you should be doing. Commonly available in India are oral examination for mouth cancer, HPV testing or a Pap smear for cervical cancer, clinical breast examination and mammography for breast cancer, and stool or colonoscopy tests for bowel cancer.

How a diagnosis is actually made

No scan alone can say for certain that something is cancer. A scan shows that a growth is there and where it sits; only looking at the cells themselves under a microscope can confirm what it is. So the path usually runs: an examination and blood tests, then imaging to find and measure anything suspicious, then a biopsy to settle the question. It can feel slow when you are waiting. Each step is deciding something the next one depends on.

The scans, and what each is for

• X-ray: quick and widely available, useful for the chest and for bones
• Ultrasound: uses sound waves, no radiation, good for the abdomen, neck, breast and for guiding a needle during biopsy
• CT: many X-rays assembled into cross-sections. Fast and detailed, and the usual choice for the chest, abdomen and for checking whether a cancer has spread
• MRI: uses magnetic fields rather than X-rays, so no ionising radiation. Better than CT at showing soft tissue, and preferred for the brain, spinal cord, pelvis and many soft-tissue tumours
• PET-CT: shows how active tissue is, not just its shape, by tracking a small dose of radioactive sugar. Used mainly for staging and for judging whether treatment is working
• Bone scan: looks for cancer that has reached the bones

Biopsy

A biopsy takes a sample of the growth so a pathologist can examine it. It may be a fine needle, a wider core needle, a sample taken through an endoscope, or a small operation, depending on where the growth is. The report that comes back names the cancer and its grade, and that report is what the whole treatment plan is built on. One thing worth saying plainly, because it stops people going: a biopsy does not make cancer spread. That is a myth, and delaying a diagnosis because of it does real harm.

What the stages mean

Broadly, stage 0 is a cancer still confined to the layer of cells it began in. Stages I and II are small or locally grown cancers that have not travelled far. Stage III usually means it has reached nearby lymph nodes or grown into neighbouring tissue. Stage IV means it has settled in a distant part of the body. The same stage can mean quite different things in different cancers, so the number is only meaningful alongside the type.

TNM

Most cancers are recorded in a system called TNM, which notes three things separately: T, the size and extent of the original tumour; N, whether nearby lymph nodes are involved and how many; and M, whether the cancer has spread to distant organs. Those three combine into the overall stage.

Grade is not the same as stage

Grade describes how abnormal the cells look under the microscope, and it hints at how quickly the cancer is likely to behave. Stage describes how far it has spread. A cancer can be high grade and early stage, or low grade and advanced. Both appear on the pathology report and both feed the plan.

The main treatments

Most people receive more than one of these, in a sequence decided by a team rather than by a single doctor:

• Surgery: removing the tumour, and often nearby lymph nodes to check them
• Radiotherapy: targeted high-energy beams that damage cancer cells in one area
• Chemotherapy: medicines that travel through the body and act on rapidly dividing cells, which is both why they work and why they cause side effects
• Targeted therapy: drugs aimed at a specific fault found in the cancer's own cells, which is why the tumour is sometimes tested genetically first
• Immunotherapy: helps the body's immune system recognise and attack cancer cells
• Hormone therapy: for cancers that grow in response to hormones, such as many breast and prostate cancers
• Stem cell or bone marrow transplant: mainly for cancers of the blood and marrow
• Palliative and supportive care: controlling pain, sickness and other symptoms. It runs alongside treatment rather than replacing it, and asking for it early is sensible, not a sign of giving up

Side effects, and what helps

Side effects depend on the treatment, the dose and the person. Common ones include tiredness, nausea, hair loss, mouth ulcers, appetite and taste changes, low blood counts and a higher risk of infection, bowel upset, numbness or tingling in the hands and feet, skin changes, and low mood. Most are temporary and most can be managed. Report them rather than enduring them, because there is usually something that helps. Between appointments, eating and drinking as well as you can, keeping gently active, and telling the team promptly about fever or bleeding all make a real difference.

Cure, remission and recurrence

Remission means the signs of cancer have reduced or disappeared. Complete remission that lasts for years is often spoken of as cure, but doctors are careful with that word, because a cancer can come back. Follow-up appointments after treatment ends exist for exactly that reason, and they are worth keeping even when you feel entirely well. Someone who has had one cancer can also develop a second, unrelated one later, which is another reason screening still applies to survivors.