The disease was first called cancer by Greek physician Hippocrates (460-370 BC). He is considered the “Father of Medicine.” Hippocrates used the terms carcinos and carcinoma to describe tumours. In Greek this means a crab. The description was named after the crab because the pincer-like spreading projections from a cancer called to mind the shape of a crab.

A tumour is defined as an abnormal growth of cells serving no useful function. These tumours maybe benign or malignant.

Benign tumours do not display any invasion into the surrounding normal tissue nor demonstrate spread via blood or lymphatic. In contrast malignant tumours demonstrate an infiltration into the surrounding normal tissue and can spread to distant sites either via the blood or lymphatics or both.

In normal cells there is a limit to the number of times it can replicate itself. This is supposed to be controlled by a gene which prevents uncontrolled replication. In cancer a mutation occurs and this gene is turned off, resulting in uncontrolled replication. Mutations can occur due to exposure to radiations, carcinogenic  toxins or cancer causing compounds and chronic irritation of an area.

To give you some examples of cancer caused by irritation, in India we have the Kangri Cancer seen in Kashmir where they hang an earthen pot in a wicker basket containing  glowing coal embers around their neck and under a  Phiran, a poncho like coat the Kashmiris wear. The constant exposure to heat on the abdomen where the Kangri is in contact causes irritation and cancer on the abdominal wall. Then there is the Saree Cancer and Dhoti  Cancer also known as waistline cancer. This occurs around the waist where the saree or dhoti is tied exactly at the same spot. The constant irritation causes cancer.

There is the cancer seen on the palate of the mouth seen in ‘chutta smokers’. This practice is seen in coastal parts of Andhra Pradesh where the homemade bidi called a chutta is smoked with the lighted end in the mouth. The lighted end comes in contact with the palate and the heat causes irritation and cancerous changes.

And of course too much exposure to the sun or ultraviolet rays could cause skin cancer.

Oral tobacco and slaked lime which is kept in the mouth for gradual continous absorption is another example of an irritant.

The constant irritation of the skin causes cell destruction and regeneration. During these cycles of destruction and regeneration a mutation in a single cell may occur causing unregulated growth. Incidence of cancer are higher in the parts of the body where there is  rapid turnover of cells because where there is a rapid turnover with replication there is a higher chance of mutation.

There is also a genetic basis for malignancy and the most famous being the BRCA 1 gene in breast cancer and RB1 gene implicated in Retinoblastoma. However possessing these genes don’t necessarily guarantee you will develop the malignancy, it just increases the probability. In order to act these genes need to get switched on and the mechanism on how they get switched on is poorly understood.

The cancer cells as mentioned before consist of rapidly replicating cells and originate from a parent cell which has undergone mutation. How closely they resemble the cells of the organ of origin is an indicator of how malignant or aggressive they will behave. This is called differentiation and the tumour could consist of well differentiated, moderately differentiated or poorly differentiated cells. A poorly differentiated malignancy will grow more rapidly because the cells have a very faint resemblance to their parents and are simple in structure and hence take a shorter time to replicate therefore grow rapidly. However a well differentiated malignancy would have a closer resemblance to it’s parent and would take a longer time to replicate.

The surgical principle behind cancer treatment depends on the degree of it’s spread or stage. If it’s localized to one area then removing the tumour along with a safe margin of surrounding tissue and if it spreads via lymphatics then removal of the lymphatics draining that area would offer a cure. The best example is in a cancer of the breast, removal of the entire breast and the draining lymph nodes of the axilla.

However if it has spread beyond it’s parent organ then it’s impossible to detect and remove all of the cancerous cells.

An anecdote to illustrate the point is that of Steve Jobs, the founder of Apple, rated the most valuable company in the USA. He had a form of pancreatic cancer,  a neuroendocrine tumour of the pancreas which are well differentiated and very amenable to treatment. As a matter of fact 30% of them are so well differentiated that they’re not strictly cancers.

All it required a removal of the tumour with a surrounding margin of the pancreas and it would have cured the disease. However Jobs was famous for his intractability, this was so often his greatest asset but may have been his undoing.

He eschewed any modern or practical treatment instead opted alternative therapies, specifically a Buddhist vegetarian approach and only when the water had risen above the nose did he seek the help of modern medicine. The pancreas was removed but then the tumour had spread to the liver. So he got a liver transplant managing to jump the que for a donor liver. This was classically the case of ‘too little too late’. He finally succumbed to his disease on the 5th of October 2011.

His famous commencement speech delivered in 2005 to the graduating batch of Stanford University, after having the second surgery.  He talked about death and guided the students by these words “Your time on this planet is limited, so stop wasting it living someone else’s life. Stop believing in other’s opinions because it destroys your mental confidence completely. The most important things in life are to follow your heart and intuition. Once you find it out, everything else in your life will become secondary.”

Angelina Jolie famously had a double mastectomy or removal of both breasts because a blood test revealed she had the BRCA 1 gene which gave her an 87% chance of developing breast cancer. She had lost her mother, grandmother and aunt to cancer so did not want to take a chance.

So how do you avoid getting cancer? Well the reason why cancer is featuring more commonly as a leading cause of death is because people are living longer. A longer life means a longer exposure to toxins, radiation and pollution, wittingly or unwittingly!

And regarding the treatment of cancer I firmly believe in the dictum, “Don’t add years to life but add life to years”. To illustrate this point I had a friend who was hale and hearty. During a routine health check up a tumour was detected in the adrenal gland and another suspicious lesion was detected in the liver which was thought to be metastases or spread from the main tumour. Since both lesions were deeply placed in the body and not amenable to biopsy, needle biopsies or introduction of a long needle into the tumour under guidance of CT scan or sonography and aspirating the lesion and examining the aspirate for presence of malignant cells. Despite repeated attempts nothing conclusive could be found. But there was a high degree of suspicion and his doctors advised that the test to be repeated.

My friend by then was tired of being treated like a pin cushion and deferred any further investigations.

He lived a normal life for three more years and then had the tests repeated, which showed the lesions had spread to the lungs. Now this was followed by a flurry consultations with various cancer specialists. A famous cancer specialist of Tata Cancer Hospital, Mumbai commented “You look very healthy for a person suffering from disseminated cancer”.

Now the tumour had already spread from the adrenal gland to the liver and the lungs. So if he had to be cured, the adrenal gland along with the liver and lungs would have to be removed and of course transplant a donor lungs and liver. Despite this you cannot guarantee that all the seedlings of the tumour have been removed.

As you can understand that would be a mammoth undertaking and would have stretched an ordinary man both financially and logistically. And I’m not sure whether such operations are  routinely done.

So he was left with the other option of chemotherapy or cancer medication.

One fact which few Oncologists explain about chemotherapy is that the drugs are extremely toxic. They are poisons delivered in controlled doses. They cause a lot of collateral damage along with the damage to the cancer cells. Just to give you an example, Mustard gas was used by the Nazis as a chemical weapon  in the second world war. It caused a lot of death and long term effects in their victims and the environment. Studies done on the victims showed that it had a destructive effect on the bone marrow. This lead to it’s use in Acute lymphoblastic leukemia, or blood cancers which originate from the bone marrow.

Now if you are are giving chemotherapy to achieve a cure then the toxic side effects are worth the reward but if you are only giving it to prolong his life by maybe 6 months to a year then is it worth it? Those additional 6 months he will be sick, nauseous, emaciated and hairless. But alive!

You have succeeded in adding years to life but failed to add life to years.

This I explained to his wife but her contention was “if we don’t give him chemotherapy he will feel that all hope is lost and will get depressed but with chemotherapy he will feel there is some hope”.

How could I argue with logic like that!

So he received chemotherapy which made him sick, fluid accumulated in his lungs and abdomen which made it difficult for him to breathe.

Imagine a previously healthy individual who was eating, drinking and enjoying now being periodically confined to hospitals. I talked to him frankly and he himself stopped the chemotherapy. But it was too late, he spent his last days in and out of hospitals with a bloated abdomen and shortness of breath. When he could have lived at least a year normally doing the things he enjoyed.

I guess we all come stamped with an ‘expiry date’ by our Maker. However this stamp is not visible and thankfully so. Our lives would be converted from ‘living’ to ‘dying’ if we knew our date with fate was so many years from hence. We would stop planning for the future.

If you meet anyone with a terminal illness who knows their journey is ending soon. They will tell you that all they chased so far, name, fame and fortune doesn’t matter anymore.

Recently I attended the funeral of a known person in the cremation ground. Simultaneously a lot of cremations were taking place, side by side. Of millionaires and of paupers. One my friends commented, “Doesn’t matter if you are rich or a pauper, in the end you will end up here”!

There was a final year medical student when I was doing MS, who complained of a backache. She was investigated and the CT Scan showed cancerous deposits in the spine. She was subject to further investigations and on passing a scope via the mouth into the stomach revealed a malignant growth in the stomach. The diagnosis was clear, cancer of the stomach with spread to the spine and on it’s journey to the spine it would have traversed the liver and lungs and left seedlings there. Luckily they followed a more pragmatic approach and were not swayed by emotions. The backache would be relieved by radiations and the primary growth left alone. Her symptoms of backache were relieved and she was able to function normally and pain free.

Despite not knowing her I decided to visit her in her hospital room. Though I have handled many terminally ill patients professionally, I have never handled a terminally ill patient socially. So I didn’t know what to expect.

I tried to put myself in her position and imagine what my mood would be like.

I would be definitely depressed and not very social.

I was very surprised to find her very cheerful and we chatted for half an hour discussing everything except her illness.

She passed away a month later but definitely she had a peaceful end.

For the physicians I would quote the ‘Medical Litany’ of Sir Robert Hutchinson,

‘From the inability to leave well alone;

From too much zeal for what is new and contempt for what is old;

From putting knowledge before wisdom,

science  before art, cleverness before

common sense;

From treating patients as cases; and

From making the cure of a disease more

grievous than its endurance, 

Good Lord, deliver us. ‘

Amen 🙏