The Changing Face Of Cancer In The Bahamas
Nassau, The Bahamas
This year nearly 1,000 Bahamians will be told they have cancer. Today around 5,000 are living with the disease but this could soar to over 10,000 by 2020 because of the remarkable advances on the horizon. There has been an explosion in our understanding of cancer as a disorder of growth control of the body's cells and we are now poised to see some incredible advances in its prevention, detection and treatment.
Cancer is associated with age - the longer we live the more likely we are to get the disease. So as healthcare round the world gets better people live longer and so the number of people with cancer inevitably rises. Of course young people and children can get cancer too but fortunately it's much rarer. You can reduce your risk of getting cancer by not smoking and eating a healthy diet - eating plenty of fresh fruit and vegetables and avoiding too much fatty food. Exercise also reduces cancer risk. Going for screening tests such as mammography and cervical smears allows cancer to be detected at an earlier phase in its evolution.
If you get any of the following symptoms you should go and see your doctor.
* A lump somewhere on your body.
* Changes in a mole on your skin.
* A cough or hoarseness that won't go away.
* A change in bowel habits.
* Difficulty in swallowing or continuing indigestion.
* Any abnormal bleeding.
* A sore or ulcer that won't heal.
* Difficulty passing urine.
* Unexplained weight loss.
* Unexplained pain.
* Feeling very tired all the time.
Cancer screening is a source of much debate. At the interface between public health, specialist care, economics and policy, it creates tensions between professional groups, politicians, the media and the public. A screening test may be cheap, but applying it to a population (with rigorous quality control and effective processing of patients with abnormal results) creates a huge workload and therefore cost. Screening can also have profound psychological effects on individuals. People with false-positive results require investigation and yet are usually eventually found not to have cancer. Unless screening can be shown to reduce the death rate from a specific cancer, the resources used are better spent on improving care, and this has led to disparities in screening recommendations between countries.
The Human Genome Project is likely to provide both new approaches to cancer risk assessment and new challenges for developing screening strategies, by risk banding populations based on changes in cancer risk genes.
Cancer is classified by the tissue in which it arises. It is a disease caused by normal cells changing so that they start to grow in an uncontrolled way. The uncontrolled growth causes a lump called a tumour to form. If not treated, the tumour will cause problems in one or more of the following ways:
* Spreading into normal tissues nearby.
* Causing pressure on other body structures.
* Spreading to other parts of the body through the lymphatic system or bloodstream.
* Causing failure of a major organ system.
* Disrupting blood flow to critical parts of the body.
There are over 200 different types of cancer because there are over 200 different types of cells in the body. The four commonest types are prostate, breast, lung and colon cancer. The initial abnormality is called the primary cancer. But it can also spread - a process called metastasis - from two Greek words meta meaning change and stasis meaning place. When cancer spreads it can damage critical organs such as the liver, lungs and brain. This ability to spread to secondary sites makes cancer potentially lethal as it can then interfere with vital body functions. Each primary site has its own characteristic pattern of spread. So breast cancer goes to bone, liver and lung whilst colon cancer likes to spread through the veins draining into the liver. Each primary cancer has its own characteristic age distribution. So breast cancer is common in women between 40 and 60 whilst prostate cancer occurs two decades later. Cancer can also occur in children although it's rare. Many children's cancers can be effectively cured by a combination of complex treatments.
Doctors that specialise in treating cancer are called oncologists. Usually the diagnosis of cancer is made by a surgeon. A biopsy is the key to making the diagnosis. This is just a piece of tissue removed by a surgeon using either a needle or by removing a larger sample under an anaesthetic. Many symptoms can be caused by cancer - the most important piece of advice is to go to your doctor if you have any progressive problem that doesn't right itself after two weeks. The biopsy sample is sent to the pathology laboratory and examined under the microscope. The pathologist is able to recognise the characteristic cancer cells with their disordered growth pattern and classify them in a way useful to the oncologist.
Once a diagnosis is made the next step is to find out how far the cancer has spread - a process called staging. We have several classification systems to stage cancer. Put simply, stage I disease is confined to the organ in which the first abnormal cells arose, stage II usually involves spread to neighbouring lymph nodes, stage III to other organs locally and stage IV widely around the body. To determine the stage of a cancer a range of diagnostic tests are used. These include blood tests, ultrasound, CT and MRI scans and sometimes some special investigations that may require going to Miami or Fort Lauderdale. The reason staging is important is that it really makes sure that the best treatment plan for an individual patient can be determined. Once the diagnostic tests are completed the oncologist creates the treatment plan. This can involve one or several of the following:
Surgery may be used to confirm a diagnosis, find out more about a cancer, as a treatment to remove the cancer or for reconstruction of part of the body. There are some excellent surgeons in the Bahamas who are able to carry out very effective treatments for most types of localized cancer.
Radiotherapy is the use of high energy rays to destroy cancer cells. It may be used to cure some cancers, to reduce the chance of recurrence or for symptom relief. There is a state of the art service run by The Cancer Centre, Bahamas using a very modern machine which provides a very effective service. Radiotherapy has to be given each day for several weeks. Going to the US for treatment is no longer necessary. Instead the Cancer Centre in Collins Avenue can provide the latest precision based techniques, including intensity modulated radiotherapy - the gold standard in terms of precision delivery. There are three radiation therapists working in Nassau, including Professor Arthur Porter who for several years was Director of the Radiation Therapy Department in Detroit.
There are over 150 different chemotherapy drugs that may be used alone or in combination. Different drugs cause different side effects and may be given in a variety of ways. Some cancers respond well to chemotherapy - others less so. Many of the drugs are given by infusion into a vein. Specialist nurses are usually responsible for giving chemotherapy although the oncologist decides on the exact prescription. In Nassau chemotherapy is given at Princess Margaret Hospital, The Cancer Centre, Bahamas, Doctors Hospital and in some doctors' offices. Most of the drugs can be given in a day unit without the need to be admitted to hospital.
Biological therapies use substances that occur naturally in the body to destroy cancer cells. They include monoclonal antibodies, cancer growth inhibitors, vaccines and gene therapy. They are a very fruitful area for further research.
Hormonal therapies alter the way hormones which occur naturally in the body affect cancer cells. They're most commonly used to treat breast and prostate cancer.
Supportive therapies can be given in addition to or as part of the main treatment. They include steroids, blood or platelet transfusions and bisphosphonates to strengthen damaged bone.
Clinical trials are medical research trials involving patients. They are carried out to try and find new and better treatments. Patients take part in trials in all areas of medicine, not just in cancer and not just to test treatment. For example, a clinical trial might be used to compare different ways of diagnosing an illness, or it might test techniques for preventing a particular cancer. Carrying out clinical trials is the only sure way to find out if a new approach to cancer care is better than the standard treatments currently used. Without trials, there is a risk that patients could be given treatments which have no advantage, waste resources and might even be harmful to them.
Dramatic progress is likely in surgery, radiotherapy and chemotherapy leading to increased cure but at a price. The completion of the human genome project will bring sophisticated genetic risk assessment requiring careful integration into screening programmes. And excellent palliative care to relieve pain and suffering must be a basic right. The next twenty years will be a time of unprecedented innovation.
Cancer will become a chronic illness, joining conditions such as diabetes, heart disease and asthma. These will impact on how people live but do not inexorably lead to death. Long-term survival will be normal even for many patients with cancers that have spread from their primary site. The political importance of cancer is huge, as voters perceive it as the most pertinent issue in health today.
Cancer treatment is undergoing a revolution. Within twenty years cancer will be a chronic disease, joining conditions such as diabetes, heart disease and asthma. These conditions impact on the way people live and not inexorably lead to death. The model of prostate cancer, where many men die with it rather than from it, will be common for most cancers. Progress will be made in prevention. Even greater progress will be made in understanding the myriad causes of cancer.
When a cancer does develop, refinements of current technologies - in imaging, radiotherapy and surgery - together with the availability of targeted drugs will make it controllable. Cure will still be sought, but will not be the only satisfactory outcome. Patients will be closely monitored after treatment, but fear that cancer will definitely kill, still prevalent today, will be replaced by an acceptance that many forms of cancer are a consequence of old age. Looking into the future is fraught with difficulties. Who could have imagined in the 1980s the impact of mobile phones, the internet and low-cost airlines on global communication? Medicine will be overtaken by similarly unexpected step changes in innovation.
More patients will benefit from better diagnosis and newer treatments, with greater emphasis on quality of life. Innovation will inevitably bring more inequality to health.
The outcome of the same quality of care differs today between socio-economic groups and will to continue to do so.
Governments will need to ensure health equity for all their constituents. Living long with good quality life even with cancer will be an achievable goal in this century.
May 02, 2011