Digestive System Cancer

Dr Praveen has specializes in the management of digestive system cancers that includes

  1. Cancer of the esophagus
  2. Cancer of the stomach
  3. Cancer of the colon
  4. Cancer of the rectum
  5. Cancer of the pancreas
  6. Cancer of the biliary tree
  7. Cancer of the liver
  8. Cancer of gallbladder
  9. Tumour of the retroperitoneum
  10. Digestive system cancers that have spread to the peritoneum

Cancers of the digestive system ( GI oncology) is a broad term covering cancers arising from different parts of the digestive system starting from esophagus to anal canal. Each segment of the digestive system is unique in the type of cells it harbours, in the way it functions and the way it responds to treatment. A cancer arising in esophagus behaves quite differently than a cancer in the colon. Thus each individual cancer needs to be treated differently and often involves a multimodal approach. And a thorough knowledge and experience of dealing with these cancers is needed for optimal care.

There have been tremendous advances in the management of digestive tract cancers. These include new treatment protocols, addition of targeted therapies, new investigative modalities, molecular profiling of tumours. In addition , there has been rapid progress in surgical oncology in terms of advanced laparoscopy and robotic surgery, cytoreductive surgeries, extended resections to give better results.

Are all digestive system cancers the same ?

Digestive system is a a collection of several organs- starting from esophagus to anal canal. Each organ has a specific function and hence contains specialized cells that are unique to that organ. Thus cancer arising in one organ is remarkably different than the one arising in another organ. Hence a pancreatic cancer cannot be treated in the same manner as a colonic cancer.

Are all digestive system cancers staged in the same manner ?

Since each organ in the digestive system is unique, the cancer arising in each organ has a unique pattern of growth and spread and cannot be compared to a cancer arising in another organ. Hence the cancer of each organ in the digestive tract has a different staging.

What are the treatment options for digestive system cancers ?

Since each organ is unique the treatment also differs considerably amongst the different organs. Broadly speaking, early stage cancers can be offered directly. Additional treatment required after surgery ( chemotherapy/ radiation) is based on the final histopathology findings.

However, in our country most of the digestive cancers are diagnosed either at a more advanced stage or when they have spread to other organs.

Advanced digestive system cancer usually requires some combination of chemotherapy before undergoing surgery. Cancers of rectum and pancreas may also need radiation before surgery. Further treatment after surgery is decided based on final histopathology.

Digestive system cancers that have spread to other organs (liver, lung, bones) are incurable. They are managed by chemotherapy.

Cancers that have spread to the peritoneum may be suitable candidates for aggressive surgical management in the form of cytoreductive surgery and HIPEC. This is depending on the primary site of cancer and the extent of the spread disease in the peritoneum.

How has the digestive system cancer treatment changed ? How advances in digestive system cancers can help patients ?

We now have better modalities to diagnose digestive system cancers. Endoscopy, endoscopic guided biopsies are widely available. Endoscopic ultrasound can precisely predict the thickness of the tumour and the layers it has breached. It also helps characterising suspicious growths in organs that are difficult to access e.g. pancreas. Endoscopy guided stenting relieves obstruction of the digestive tract at multiple places e.g. rectal cancer, colonic cancer, pancreatic cancer, cholangiocarcinoma.

CT and MRI technology also has improved drastically. Multiplanar and multiphasic CT scans help us in understanding the tumour anatomy precisely so that surgery can be planned to the last detail. As a result of this, surgical time is reduced and results are improved. MRI of the rectum has revolutionized the management of rectal cancer. The choice of preoperative radiation and chemotherapy, sphincter preservation, plane of surgery and extent of surgery – all are decided by the MRI of the rectum.

With the better understanding of the cancer and surgical anatomy we have been able to constantly try and push the surgical boundaries. The advancement in technology helps us. Minimal access surgery for esophagus and endometrial cancer, vascular resections for pancreatic cancers, image guided surgery for liver metastasis, sphincter saving surgeries for low rectal cancers, cytoreductive surgeries for peritoneal spread are some of the examples of surgical advances in digestive tract cancer surgery that have proven to improve outcomes.

Due to the lack of screening programs most of the digestive tract cancers in the country are diagnosed at a fairly advanced stage. In such a setting chemotherapy ( sometimes radiation also) before surgery has been shown to improve survival in every organ, starting from esophagus to rectum.

Genetic mutations are what drive the cancer. And studying the mutations gives us deeper insight into the working of a cancer and provides ways to counter its growth. Mutation analysis is now available in major labs of the country. These tests help us in deciding whether additional treatment is necessary and what type of therapy is expected to give better results.

The need to individualize treatment :

There are guidelines for practically every stage of cancer of every organ. These are published by reputed national and international societies and are backed by robust scientific evidence.

However, What these guidelines lack is consideration to the circumstances of treatment. Patient’s financial status, social circumstances, logistics and aspirations have to be taken into consideration in decision making while not compromising the treatment standards. This requires tweaking of recommendations to suit the needs of the patients.

Value of multidisciplinary management:

Digestive system cancers are few of those cancers that require multi modality treatment in most of the situations. Hence collaboration with medical oncologist and radiation oncologist in treatment decisions is desirable. As a specialist in one branch one’s knowledge of advances in other fields is often limited. Hence such a collaboration helps in making sure the patient gets the best possible treatment.

The value of comprehensive team care in prehabilitation and postoperative rehabilitation:

Digestive system cancer directly impairs a patient’s nutrition. Hence most patients suffering from these cancers are nutritionally deprived. This affects physiology of every organ- respiration, muscle power, immunity etc. Most patients adjust to this new state by limitation of activity. Hence undernourishment goes unnoticed. Nutritional deficiency and limitation of activity form a vicious circle. Several of these patients are elderly. Research has consistently shown the positive effect nutritional intervention has on treatment results. Hence we believe nutrition is as important as treatment itself.

Cancer treatment be it radiation, chemotherapy or surgery puts considerable physiological and psycho-social stress. Hence a well nourished patient with positive outlooks is more likely to tolerate the treatment well compared to a nutritionally deprived and distressed patient. Nutritional rehabilitation, physiotherapy, mental well being have been shown to have improved the results of cancer treatment.

Out of the three cancer treatment modalities, surgery produces the maximal physiological stress. Hence a thorough preparation for surgery is necessary for optimal results. Such a preparation ideally begins much before surgery and most desirably right from the time cancer is diagnosed and involves nutritional intervention, physiotherapy, respiratory optimization and psychological support. With adequate time for such a preparation- the opportunity to improve the body’s protein reserves, muscle strength, immunity, respiratory reserve and outlook towards treatment- is huge. This directly affects the outcomes of the surgery.

Hence we believe each patient needs a comprehensive assessment and care – that not only involves cancer specialists –but also nutritionists, physiotherapists, psychiatrists, psychologists and home care nurses. This way not only the cancer treatment becomes successful but also the patient actually sees a betterment in the quality of life during and after treatment.

Performing a surgery is a combination of knowledge, skills, training and experience. Even complex minimal access surgeries like pancreatic cancer surgery, liver cancer surgery, partial nephrectomy can be performed by experienced and skilled surgeons with excellent results. More than one cancer affected organs also can be resected using laparoscopy or robotic surgery. The feasibility of minimal access surgery has to be balanced with oncological safety to achieve optimal results.

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