About Dr Devendra Goyal:
Dr Devendra Goyal is a Radiologist with particular experience in Radio Oncology. He completed his MD in Radiology and has been working as a senior resident in Tata Memorial Hospital for four years.
In this article, he talks about the various cancer treatment processes, the side effects, how vital the role of the nutritionist is, cancer treatments during the times of Covid and most importantly about the psychological aspects of cancer and the stigma associated with it.
What are the various modalities used in cancer treatment in India?
At the onset, we get a couple of necessary tests to confirm whether it is cancer or not. If it is confirmed, we divide the patients into two streams, according to whether they are in a curative stage or palliative stage. If the patient is curative, we do everything to cure the disease completely. The primary modality is surgery, and as an additional measure, chemotherapy and radiation are given so that even the smallest micrometastases, which are invisible to any investigation, are cured. In the cases where it has already spread to an extent where we cannot completely cure it, we do every measure possible to provide maximum pain relief and comfort to the patient from the effects of cancer
What the side- effects that a patient has to suffer and what role does a nutritionist play in reducing these side effects?
Cancers are ultimately cells, and whatever cancer treatment you are receiving (except surgery) is directed towards stopping the growth of those cells in the body. Inadvertently, this also affects the skin, hair and the lining of our gut as these keep getting removed and regrowing again. This is the reason for the side effects such as loss of hair, skin rashes, diarrhoea, loss of appetite and vomiting but these effects are inevitable, even though our best efforts are done to minimalize them. Extensive research is being done to reduce the effects of cancer treatment, but this is a continuously evolving process, which will take time.
This is where nutritionists play a significant role that is often undermined. It is crucial to ensure that the body contains the necessary amount of proteins, fat and muscle mass. Often, cancer would be compounded with other issues like diabetes, hypertension or renal disease, which leaves a mark on your daily diet. It is necessary to have a nutritionist in every Cancer hospital to ensure that muscle- mass, calorie intake and other factors are up to the required mark, keeping in mind each individual’s unique needs and restrictions.
Could you provide us with an insight into Sarcopenia and Radiology?
‘Sarco’ means muscle and ‘penia’ implies loss. Sarcopenia is a very recent concept that was unheard of before 2000. It started in Europe with studies done on geriatric people and quantifying the age at which they started losing muscle mass.
Cancer cells thrive by using up the nutrition meant for the other cells in our body. These cells grow at a much faster rate, resulting in the muscles losing proteins and eventually Sarcopenia. These patients will have more complications during their treatment, such as vomiting during chemotherapy, more hair loss and their GI tract may not tolerate food and such. Sometimes, post radiation, they will have fractures in their vertebral column since they don’t have enough protein in their body. A nutritionist will be able to reduce the complications of these patients and offer a better chance of recovery.
When you treat a patient for cancer, it is always necessary to take scans, either CT scan or PET scan. This is always essential because, without imaging, you can never know how to diagnose, understand what stage it is, or decide about your cancer treatment.
There is specialized software, which is very expensive currently, which can outline compartments in your body. We are trying to develop cheaper ones for our country, which can compartmentalize the fat beneath your skin, the muscle, the fat within your tummy, and the muscle within the organs. This will help to find Sarcopenia at a more basic level without any extra expenditure.
What are the reasons for the rising trends in Lung, Head and Neck cancer?
The data coming out on this is very alarming as most of these cases are habit- related. In the 1950s, doctors used to prescribe cigarettes to women to decrease nausea during the first three months of their pregnancy since they didn’t know that it could be harmful. Then extensive data started emerging that smoking is detrimental to both pregnant women and the baby, and causes cancer, and lead to a decrease in smoking.
Head and neck cancer in India are high, also due to the damaging habits such as chewing tobacco and betel leaves. North Indians predominantly have a habit of keeping chewed leaves (tobacco and betel) inside their mouth and sleeping overnight, which is so harmful. It is tough to make these people stop their habits even after contracting cancer. While smokers have nicotine patches that they can use for de-addiction, these people have no such measures.
The only way to prevent this is to conduct wide-scale awareness programs at the grass-root level. They should be made aware to consult a doctor as soon as they find an ulcer in their mouth. You can get 200 institutes across the country, but nothing will compare to robust prevention and awareness programs.
What are your comments on the high costs for cancer treatment and diagnosis?
The people in our country have very high pain tolerance, but the sad part is that this is due to their lack of money. They consider going to the doctor as a waste of money and that nothing good will come out of it. Being a developing nation, it is imperative that the majority of our patients need to be taken care of in a government institution, of an acceptable level.
Equally essential is finding the right doctor for your diagnosis. If a woman feels a lump in her breast and goes to a doctor who is not aware of the biologics of breast cancer, they will simply remove the breast and send them to some territory government sponsored hospital, by which time, the cancer would have already spread to other parts of the body. She might have reached a situation where the surgery couldn’t have done much good, but ends up using her financial resources for a surgery, for no avail. Getting a second opinion also matters as some doctors schedule for the surgery the very next day after the first consultation to make sure that they do the surgery there itself, and use the patients’ plight for their self-gain. By the time they come out of the post-op recovery ward after four weeks, their cancer would have spread throughout the body. Thus, consulting the right doctor at the right time can save both your life and money.
Doctors need to be clear in their treatment intent. If cancer has spread, do not operate. “It takes five years to learn when to operate and 15 years to learn when not to. It is easy putting a knife or needle but difficult stopping yourself and saying no, this is something which should not be touched, let’s work it up further”. That is a crucial part of cancer treatment.
There is a welcome change with the increased number of medical claims covered through PM Yojana and state-sponsored schemes. This is very important because if you are paying insurance, at least your primary back up will be ready.
In this cancer journey, you need mental, emotional and psychological support too. In the US, the first thing to get listed for liver transplantation in case of liver cancer( majorly due to alcohol consumption), is having familial support because they know if they don’t have familial support, then patients will relapse into drinking. They will not register you if you don’t have a family supporting you emotionally and psychologically.
Could you talk us through cancer treatment during these times of Covid?
Covid is something that struck out of the blue, unplanned, and can be classified as a natural disaster. But we cannot stop our treatments due to it and have to adapt. If a Covid positive patient has a tumour that needs to be urgently removed, the doctors should do their duty following the necessary guidelines such as wearing N-95 mask, face sheet, PPE kit, gloves and such. Unless they have some genuine reasons such as asthma or other health concerns themselves, one should not deny cancer treatment, or any treatment for that matter, due to Covid.
The follow up of cancer patients can be done through teleconsultation rather than forcing them to come from distant places. They can take the necessary scans and blood tests from a scanning centre near their house and send the details through e-mail, according to which the doctors will be able to guide them. You can always tell them to do a re-consultation after the Covid passes off. But in cases where the patient is showing terrible symptoms or uncertain diagnosis, then we should call them to the hospital because we don’t want to take any chances.
What are your thoughts about the situation of the caregiver and the stigma associated with cancer?
Cancer is a burden for both the patients and their caregivers. After the patient, it is the caregiver who suffers the most. They always need to make sure that they provide emotional and psychological support; that the patient doesn’t lose hope. The caregivers should take necessary care of themselves, going to a support group, talking to family and sharing your problems. There will be people who psychologically affect them, whom they should avoid and try to keep only positive people in their life.
The stigma associated with cancer is enormous, even in today’s times. I will share an episode about a male patient who had breast cancer. He used to come for mammography on 27 February every year and used to be the first patient in the queue every year. I asked him why he used to come so early, living so far, to which he replied that his son and daughter- in- law were unaware of the fact that he had breast cancer. He was afraid how his society would react to the news and whether they would have to leave the society due to this.
He got operated and cured, and only his wife is aware of the fact that he had breast cancer. He used to come for the mammography under the pretext of going to the park, get his tests done and asked me to check his reports early. He was the first one to come to the OPD and the first to return in the afternoon.
The stigma associated with male breast cancer in India is unimaginable. If his wife had the same thoughts as the neighbours, then just try imagining the psychological pressure on the patient’s mind. ‘What will society say’ is such a big thing in cancer and people should be more vocal about it.
Is it wise to go and get your tests done if you doubt that you have cancer just because you have cancer history?
If you have a family history of cancer, then get yourself a good medical insurance first, so that even if you have to get tested again, it is something you can afford. Instead of preventing a test, get the right medical insurance, because that is very critical.
It is essential to notice the changes taking place in your body and not to see any symptom slightly. Some symptoms will be too weak to make you sit up and notice. For example, ovarian cancer grows very slowly; they don’t cause any symptoms, except mild pain in the abdomen. If you take paracetamol, the pain will go away. So do not ignore anything, which keeps you paining for more than a week or month because that means something is constantly going on inside you. 95% of times, it won’t be cancer, but that 5% of times, your life will be saved. Never ignore a chronic symptom, because everyone can take care of acute things, but chronic things such as a small lump should not be ignored and kept aside for another day.
It is always better to get yourself tested at least once a year. Never put off doing a test for tomorrow when you can do it today itself. This goes a long way in surviving cancer too. Finally, don’t be afraid of cancer; you just need to have a positive approach in your fight against it.