Ques: What are the most common GI cancers seen in the Indian population?
Ans: Common GI cancers seen in the Indian population are cancers of the large intestine, gall bladder, stomach, pancreas, esophagus amongst others. Cancer of the liver is commonly seen in patients with cirrhosis.
Ques: What are the common risk factors associated with the development of cancers?
Ans: Different cancers have different risk factors however few common associations are seen. A few common associations that are attributed are the use of tobacco products, smoking, alcohol, obesity, chronic inflammation, radiation exposure, use of immunosuppressive agents etc. GI cancers In general should be suspected in an older patient with unintentional significant loss of weight ( >5 kgs in one month, >10 kgs in 3 months) associated with severe loss of appetite.
Ques: What can be done to prevent the development of these cancers?
Ans: In general, leading a healthy lifestyle, weight control and reduction, and avoidance of known risk factors are recommended. In addition, timely management of premalignant conditions associated with different GI Cancers is recommended. Avoiding exposure to different risk factors and understanding hereditary risk factors is important to reduce the incidence of GI Cancers.
Ques: What are the risk factors and premalignant conditions for liver cancers?
Ans: In general, liver cancers are uncommon. However, if you have chronic liver disease or cirrhosis, you are at increased risk of liver cancer. All such patients are advised to undergo treatment if inflicted with Hepatitis B or Hepatitis C for which effective treatment is now available. Alcohol is another risk factor for cirrhosis and should be stopped immediately. While the banning of alcohol is a welcome move in Bihar from a healthy perspective, patients with a prolonged history of alcohol intake may already have cirrhosis or may develop cirrhosis. All cirrhotic patient should regularly visit their doctors every 3-6 months for USG evaluation for the development of cancer. Treatment for liver cancer is available if diagnosed timely with survival up to 70-80% at 5 yrs. Treatment requires a liver transplant in a majority of cases however a few selected cases may be amenable to liver resection.
Ques: What are the premalignant conditions and risk factors for the development of Gall bladder cancer?
Ans: Gall bladder cancer is very common in northern India, especially in the Gangetic plain. Nobody for sure why this is so. However, what we know is that gall bladder cancer is fast-growing cancer associated with poor outcomes. Survival may be limited to 6 months or 1 year without treatment. The most common association is seen with gall stones. However, there is no reason to panic if you have gallstones which are easily treatable conditions compared to cancer. Not all cases of gallstones develop cancer. In one study < 1% of all gallbladders with stones had cancer on final biopsy after gall bladder removal.
However, gallstones are seen in > 90% of gallbladder cancer patients.
Your ultra-sonologist will be able to tell you if you might have gall bladder cancer. A CT scan should further investigate any thickening of gall bladder wall > 3mm on USG. It is better to err on the safe side at this point since if diagnosed at an early stage gallbladder cancer may be curable. Other findings that may be associated with gall bladder cancers are polyps in the gall bladder wall, calcification in the gall bladder wall, associated choledochal cyst, focal thickening and infiltration into the liver etc. These are alarming findings and should be further investigated without delay. At this stage, gall bladder cancer may be cured with surgery with good survival.
Ques: What are the premalignant conditions and risk factors for the development of cancers of large intestines?
Ans: Large Intestine essentially is composed of Ascending colon, transverse colon, descending colon, sigmoid colon and Rectum. It ends in the anal canal. Premalignant conditions associated with colon and rectal cancer are Polyps, Ulcerative colitis, Crohn's disease, Familial adenomatous polyposis, and Hereditary Non-polyposis colon cancer syndromes, and radiation exposure amongst others. If you have a history of colon or rectal cancer in the family, then you are at a definite increased risk of developing cancer of the large intestine. In developed countries, routine surveillance via colonoscopy is recommended after 50 years of age and also earlier and more frequently if you have a known risk factor. Usual symptoms associated are altered bowel habits, the altered colour of stool ( red, brown or black), unintentional significant weight loss, loss of appetite, lethargy etc. If you have any of these factors you should undergo further investigations preferably colonoscopy to rule out or diagnose the disease. Early diagnosis and treatment are associated with prolonged and better survival. Surgical treatment for these cancers is available if diagnosed early.
Ques: What is meant by altered bowel habits?
Ans: Altered bowel habits are a constellation of symptoms that require special attention. Any recent change in your vowel habits constitutes an altered bowel habit. If you have never been constipated before and you develop constipation that could be one of the signs. If you cleared your bowel once or twice daily before but now you go four to five times daily that could be one of the signs. If you have just passed stools and immediately feel the sensation again, it could be one of the signs. If you have just passed stool but feel incompletely evacuated, it could be one of the signs. Sometimes blockage of the large intestines due to this cancer might lead to obstruction with abdominal swelling and may later burst which becomes an emergency. These symptoms if present for some time or happen with most of the stool episodes should be further investigated.
Ques: What are the premalignant conditions and risk factors for the development of oesophagal cancer?
Ans: Esophageal cancers are notorious for coming to treatment at an advanced stage when they are beyond surgical treatment. This is because the principal symptom
suggestive of esophageal cancer is dysphagia (difficulty to swallow) that occurs very late. The esophagus dilates to accommodate the swallowing process until it can dilate no more. It is then that dysphagia develops and usually at this stage it is beyond what is curable. However, the premalignant conditions associated with esophageal cancer include Barrett’s esophagus, High-grade dysplasia, a history of caustic burns, and a history of radiation amongst others. Barrett’s esophagus is usually a sequelae of Gastroesophageal reflux disease ( GERD) which is quite common in the Indian population. The symptoms suggestive of GERD include pain in the mid-chest or mid-upper abdomen especially after a meal, heartburn, bitter aftertaste with regurgitation in the mouth, the sensation of a balloon being inflated in the chest, excessive belching etc. If your symptoms are not controlled on oral medications or you have any of these conditions for a prolonged period of time an endoscopic examination of the upper gastrointestinal tract is required. Other risk factors commonly associated are smoking, alcohol, advanced age, history of previous head or neck cancer, obesity etc. If you are looking for gastrointestinal cancer treatment in Delhi then book an appointment with Manipal Hospital now.
Ques: How to diagnose and treat esophageal cancer?
Ans: Esophageal cancers unfortunately are diagnosed late when they are beyond curative treatment. However, they can be caught early if we pay attention to the above-mentioned symptoms and get promptly investigated. Upper gastrointestinal endoscopy should be promptly done to diagnose and biopsied to confirm this condition. Survival after early diagnosis has consistently improved over the years with multimodality treatment of which timely surgery is a huge part. We offer complete multimodality treatment protocols for all such patients. However early diagnosis is very important in oesophagal cancers.
Ques: What are the signs and symptoms of Pancreatic cancer?
Ans: Pancreatic cancers of the periampullary region usually present with Jaundice, Itching, dark yellow coloured urine and altered colour of stool ( usually light coloured or occasionally black coloured). This happens because cancer blocks the flow of bile into the intestine, hence causing the above-mentioned symptoms. The patient may or may not have pain associated with it. Cancers of the bile duct may also present with similar symptoms. However, cancers of the tail of the pancreas may only have abdominal pain or discomfort. Associated unintentional significant weight loss ( > 5 kg in last one month or >10 kg in last 3 months) in an older patient is mostly an ominous sign. If you have any of the mentioned symptoms then contact the gastroenterology hospital in Delhi.
Ques: How to diagnose pancreatic cancer early?
Ans: USG showing dilatation of biliary ducts( extra and intrahepatic ) without gallstones should be further investigated. A good contrast-enhanced CT scan with pancreatic protocol should be done in these patients to delineate the lesion. All such patients should have a CT scan done promptly to rule out pancreatic or bile duct cancer or to diagnose it early. Endoscopy may be done in these cases to perform a biopsy and get a tissue diagnosis. An MRI may also be performed to further characterize the doubtful lesions. The point I want to stress is that any such findings on USG should immediately get a CT scan to increase the chances of curative surgery.
Ques: Does pancreatic surgery always lead to diabetes?
Ans: Usually only a part of the pancreas is removed, hence patients do not develop diabetes as the remaining pancreas compensates.
Ques: What are the features of stomach ( gastric ) cancer?
Ans: Gastric cancers are commonly seen tumours in southern India and extreme northern regions of India. Patients with gastric cancer have anorexia, significant weight loss, early satiety, dysphagia ( difficulty in swallowing), vomiting (2-3 hrs after meals ), bloody vomitus, abdominal lump, and chronic upper abdominal discomfort (Gastritis) amongst others.
Ques: How can gastric cancer be diagnosed early?
Ans: Any of the above-mentioned symptoms should not be ignored especially in an older patient. The stomach is accessible via endoscopy and a diagnosis can be made with confirmation by biopsy. Any ulcers. polyps or evidence of chronic gastritis has a higher risk of malignancy and should be adequately biopsied. Your doctor may also order a CT scan to see whether the tumour stage is amenable to curative resection or not. Broadly, surgical
treatment is the only curative treatment available for gastric cancer.
Ques: What is the most critical factor for early diagnosis of Gastrointestinal (GI) Cancer?
Ans: Understanding the signs and symptoms as mentioned above coupled with prompt investigations with CT/MRI and Endoscopy is a critical factor for diagnosis. Early diagnosis with biopsy at an early stage with curative treatment is uniformly associated with better survival across all GI cancers.
Ques: Is biopsy mandatory and important in all GI and HPB cancers before surgery?
Ans: In oesophagal, gastric and colorectal cancers where the alimentary tract is readily accessible via endoscopy, biopsy confirmation is mandatory if clinical condition permits. In pancreatic cancer and bile duct cancer, an attempt should be made to obtain a biopsy however it's not mandatory if the clinical features are suggestive of cancer. In Gall bladder cancer, any form of biopsy is contraindicated except those diagnosed on cholecystectomy specimens. In Liver cancers, the typical morphology seen on CT/MRI is enough to proceed with curative surgery without biopsy confirmation.
Ques: What would be your final message to the general public?
Ans: Lead a healthy and fit lifestyle free from smoking and alcohol. Participate in regular health check-up programs, especially after 50 yrs of age. Invest in a good health insurance policy since healthcare costs are going up steadily. The most important message is that educate yourself about these symptoms we just discussed and visit a gastroenterologist in Delhi if you develop any such symptoms to get adequately investigated.
Consultant - HPB Surgery & Liver Transplant
Manipal Hospital, Dwarka-Delhi
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