Modern radiation techniques for treating gynaecological cancers

What are gynecological cancers?­

A. Cancers of the female reproductive organs are called gynecological cancers. Among these are cancer of the body of the uterus (endometrial cancer), opening of the uterus (cancer of cervix), ovary, vagina and vulva.

 Q. What is radiotherapy?

A. Radiotherapy is one of the three methods of treating cancer, the other two being surgery and chemotherapy. Also called radiation or radiation oncology, this modality of cancer treatment involves targeting cancer with x rays or gamma rays and rarely, with  charged particles such as electrons and protons.

Q. What are modern radiation techniques?

A. Modern radiotherapy techniques are treatment methods that consist of computerised  modeling  of patients’ anatomy, software programs that, under direction of a radiation oncologist,  target cancer and protect normal tissues. In addition, synonymous with these techniques is the use of sophisticated hardware, i.e. treatment machines called linear accelerators, which have devices that shape the radiation to match the shape of the tumour. Some advanced linear accelerators also have provision for X rays or CT scans before or during a patient’s treatment session, to ensure accurate focusing of the radiation beam.

Q. How do modern radiation techniques help in better treatment of cervical cancer?

A. Radiotherapy is the main treatment for cervical cancer, except in very early stages when surgery may be used alone or in combination with radiotherapy.  Various modern radiotherapy techniques ensure safe and effective treatment for this cancer. These are IMRT or RapidArc, to reduce the effects of radiotherapy on normal structures adjacent to the cancer, i.e. small and large bowel, urinary bladder and bone marrow. Another technique, IGRT, which may be used in addition to IMRT / RapidArc, is aimed at ensuring accurate treatment by accounting for, and correcting,  changes in the patients position in reference to the treatment machine, i.e. linear accelerator , as well as changes in the internal organs vis a vis one another. The latter happens because of routine body functions like presence of urine, gas and stool  in the bladder and bowel, respectively.

Q. What is brachytherapy and is there some advance in this method too?

A. Brachytherapy is internal radiotherapy, i.e. insertion of a radiation source into the affected organ, delivering treatment in proximity to the tumour. Traditionally planned using x-rays, image guided brachytherapy is an advance wherein the radiation is directed on the basis of CT or MR scan, ensuring a dramatic improvement in efficacy. This is because x ray based planning incorporate neither  information of patients' anatomy nor that of the volume and extent of the cancer in an individual patient.  I practise  MR based brachytherapy   for cervix and am very satisfied  both with the additional  information that is received by doing an MRI as well as the outcomes achieved.

Q. How are intracavitary and interstitial brachytherapy different from each other. Intracavitary radiotherapy , the more common form of brachytherapy in cervical cancer consists of insertion of hollow applicators into the uterus and cervix using the body's normal passage and then inserting a  radiation source into these hollow applicators. Interstitial radiotherapy is used when the disease extends  farther away from the reach of applicators placed in the uterus and vagina.

Q. What has been the impact of these modern radiotherapy techniques on cure rates in cervical cancer? Is this dependent on the treatment machine?

A. There has been a significant improvement in outcomes even in advanced stages of cervical cancer/ cancer cervix. While the equipment is important, the  knowledge & skill set of the treating radiation oncologist and  meticulous attention to detail  by the treating  team, in each patient, is essential to  ensure correct treatment and extract the best from the treatment machine.

Q. What is the role of modern radiotherapy in endometrial cancer (body of uterus)?

A. Primarily treated with surgery, radiotherapy is used as post operative treatment in nearly all stages. The treatment varies according to the stage of the disease; modern radiation techniques have an important role in preventing recurrence of cancer and reducing side- effects. The treatment may comprise of external beam radiotherapy i.e. IMRT / RapidArc with or without IGRT or may be in the form of brachytherapy for the vagina. In some situations, these may be combined.

Q. What about other gynecological cancers?

A. Cancers of the vagina require radiotherapy.   Cancer of the  vulva, i.e. the external reproductive organs may be treated either with surgery or with a combination of radiotherapy and chemotherapy. The primary cancer is treated, along with lymph glands that lie in the groin. Here too, IMRT helps treat the cancer while sparing  adjacent normal organs.

Radiotherapy is used in special situations in the treatment of cancer of ovary.

Alcohol Consumption & the Risk of Cancer

Q1.  Does consuming alcohol increase the risk of developing cancer?

A1. Yes, consuming alcohol increases the risk of developing cancer. This risk is more in heavy drinkers but significant in all persons who consume alcohol regularly.

Q2. What are the reasons for this increased risk?

A2. The reasons are varied. Some of these reasons are that alcohol increases inflammation in some organs of the body, leads to nutritional deficiency, increases the amount of the female hormone estrogen in the body and causes obesity.Other factors are reduction of the immunity of the body as well as an increase in the harmful effects of tobacco.

Q3. Does this increased risk pertain to some specific cancers and if so, which cancers are these?

A3. Alcohol increases the risk of cancer of the mouth, throat, food-pipe, large intestine, liver and breast.

Q4. Why does alcohol increase the risk of developing cancer of the alimentary tract, i.e.,  throat, food pipe and  intestine.

A4. Alcohol is metabolised into a toxic substance called acetaldehyde which causes inflammation in the alimentary tract.  In addition, it also potentiates the ill effects of tobacco by increasing  the absorption of carcinogens (cancer causing substances).

Q5. Does alcohol increase the risk of cancer of the breast in older women, or is age irrelevant ?

A5. Alcohol increases the level of oestrogen in the body and this in turn leads to an increased risk of breast cancer, irrespective of the age or menopausal status of a woman. The increased risk of breast cancer is also related to obesity and the deficiency  of folates induced by alcohol.

Q6. Alcohol induces cirrhosis of the liver. Is that somehow related to cancer?

A6. Yes, the same inflammatory process that causes cirrhosis of the liver also causes cancer. Liver cancer is one of the most common causes of cancer related death worldwide, though all of this is not related to alcohol.

Q7. How significant is the problem of alcohol related cancer in the Indian context.

A7.Though less significant than countries like China or the developed world, alcohol is an important cause of cancer in Indian men, with over 7 % of cancers in Indian males being attributed to alcohol. Happily, the number of alcohol induced cancers  in Indian women is negligible.

Q8. Does stopping the intake of alcohol help?

A8. Stopping the consumption of alcohol helps but slowly, the risk of developing cancers becoming equivalent to a non drinker in about ten years.

Pap smear: Why, when, how ?

Pap smear: Why, when, how?

A few facts about female anatomy: The womb is also known as the uterus. It communicates with the vaginal canal; its opening into the vaginal canal is called cervix.

What is a Pap smear?

The name Pap is derived from the name of Dr.   George Papanicolaou, the originator of the Pap test. This is a simple painless test comprising two steps. The first step is collection of easily shed / scraped off cells from the opening of the womb i.e. the cervix, on a slide or in a bottle. The second step is examination of these cells under the microscope by a cytopathologist to detect abnormal cells.

What does an abnormal Pap smear indicate?

An abnormal Pap may indicate inflammation, infection, precancerous or cancerous change.

 

How does finding pre cancerous cells help?

Cancer of the cervix is India’s most common cancer as well as that of the developing world. It mainly occurs as a consequence of infection with the human papilloma virus. This infection results in transformation of  cells in the region of the cervix into abnormal dysplastic cells. Dysplastic cells left untreated, may transform into cancerous cells over a few years. However, if identified by a Pap smear and treated, conversion to cancer may be prevented. 

Why is a simple gynecological examination inadequate to do what a pap smear does?

Pap smears help in identifying abnormalities that are not visible  to the naked eye during examination. An abnormal pap smear in a lady with no obvious abnormal finding on examination, prompts the doctor to examine her under magnification using an instrument called colposcope. 

Who should undergo a Pap smear?

All women between the ages of 21 and 65-70 years, who are or have been sexually active, should undergo a Pap smear examination. 

How long does a Pap smear take? Is it painful?

Pap smears take around 5 minutes to perform. There is no pain; there may be some mild, transient, discomfort.

When should this test be performed?

The ideal time for women to undergo this test is 10 to 20 days after their period. Women who have undergone menopause may get the test done anytime.

It should be performed every 3 years. In case the test reveals an abnormality, a repeat test may be advised earlier than 3 years.

Why should a woman get a Pap test done?

The incidence of cervical cancer is very high in the developing world. The map above, courtesy the GLOBOCAN project,  illustrates the magnitude of the problem in South Asia, Africa and Latin America. A quarter of the world’s cancer cervix patients are Indian!

Pap smears can prevent this cancer, since precancerous abnormalities are amenable to outpatient gynecological procedures.

In patients in whom this disease has already occurred but is not causing symptoms, Pap smears may help detect the disease at an earlier stage.

In countries where Pap smears are performed regularly for screening, cervical cancer has become very infrequent.