When you hear hoofbeats
What steps can we take to deal with cancer in time?
In an earlier article, I mentioned a reprieve from jail on a personal 9/11. A few pointers over almost a year had led to clouds of suspicion closing in. I decided, "when you hear hoofbeats, don't think zebras," went to Tata Memorial Centre (TMC), Mumbai in the teeth of prevarications by my doctors and was diagnosed with prostate cancer. It has been a hectic year of trial and error, hard choices, course corrections, riding an emotional roller coaster and playing social hide – and – seek. Here are a few things I learnt during this long journey.
Firstly, what is cancer? It is a disease caused by the uncontrolled growth of a single cell. The growth is unleashed by mutations – changes in DNA that specifically affect genes that incite unlimited cell growth. In a normal cell, powerful genetic circuits regulate cell division and cell death. In a cancer cell, these circuits have been broken, unleashing a cell that cannot stop growing and multiplying. Till date, why and how the mutations occur is a mystery.
Secondly, no one says someone "had" cancer. They say someone "has" cancer. The reason is, the disease is inventive. Even when one is "cured", one has entered on a one-way passport to the "kingdom of cancer", you cannot leave because you are under surveillance, treatment and retreatment all the time. The "cure" revolves around three strategies, radiation, surgery and chemicals – hot ray, cold knife and drugs – each with its own upside and downside. In the case of prostate cancer, if the cancer is confined to the prostate and if one opts for surgery, the entire prostate is taken out and may result in a complete "cure." However, the downside is, there are side effects of incontinence, sexual dysfunction and infertility. While infertility is permanent, incontinence and sexual dysfunction improve over time and the improvement depends upon how much of the concerned nerves (which surround the prostate) is spared. Radiation therapy uses gamma rays to kill cancer cells but they kill nearby healthy cells also. Chemotherapy uses chemical drugs to kill the cancer cells and affects normal cells also. The chemicals are extremely toxic although, for certain types of cancer, some non-toxic chemicals have been discovered.
Can cancer be prevented? Based on my readings, I feel, with the current level of knowledge, the short answer is no, not really. We still do not know why cells mutate. Some associations with certain physical, chemical and genetic phenomena have been established so reducing exposure to them may reduce the chances but it takes just one cell amongst the trillions in the body to have aberrant behaviour resulting in cancer. The prognosis is better, the earlier the cancer is detected. So, can we take action to detect it early? Again, for certain cancers, maybe, but not really for most of the cancers. Meanwhile, by the time the symptoms of a cancer appear, it is usually too late for a complete cure. The only possibility is to go through life with moderation in everything and pray that one does not get visited upon by the "king of terrors." Also pray that if it happens, it is detected early.
Fourth, for prostate cancer, doctors have not found any association with any factor except age. There is a lot of debate surrounding whether to have regular PSA screening. Prostate biopsy carries a certain amount of risk. Doctors tend to progress from PSA test through Digital Rectal Examination (DRE) to biopsy. However, one important diagnostic tool is an MRI of the lower abdomen. For some reason, doctors tend not to prescribe it. In my case, the MRI crystallised the possibility of the tumour even though repeated DREs did not indicate it. MRI is also a non – invasive tool. I feel this should be used.
Fifth, in my case, only two of the 12 biopsy cores indicated cancer. The Gleason score was 3 + 3 which indicated a non-aggressive, slow-growing cancer. The standard protocol for such cases is "active surveillance" which, in India, means PSA tests every six months and annual biopsy. I chose to go for the surgery because (i) progression of cancer is unpredictable, (ii) I did not want to play chicken with death, hanging on life's edge, (iii) if there was to be surgery at some point, I wanted it sooner rather than later, (iv) I was beyond the desirable age for procreation, (v) the final Gleason score tends to be higher than the biopsy score because biopsy result pertains to only the 12 cores taken out and is not necessarily the comprehensive picture. However, each patient's circumstance is different and this would be a personal choice, to be taken with some care.
Sixth, I would recommend that, in India, the moment cancer is even a mere suspicion, one should rush to TMC, Mumbai. They have seen huge numbers of cases of all types of cancer, have the best equipment and have developed robust protocols.
Seventh, after the diagnosis, the treatment decision should determine the hospital and the doctor. For prostate cancer, the very best surgical option is available in India through the three top doctors in the world visiting India and performing surgery. Even otherwise, at TMC, one is assured of surgery of a high quality with the latest version of the Da Vinci robot.
If I had informed the doctor that I was taking Dutasteride, my diagnosis would possibly have happened almost a year earlier. In PSA, a score above 4 is considered suspicious and that above 10 is considered dangerous. However, John Kerry, the once USA Presidential aspirant, got himself biopsied with a PSA score of 3.24 ng/ ml because it had shown a 70 per cent increase over two years. He was diagnosed with prostate cancer and opted for surgery which cured him. The rate of increase in the PSA score should also be monitored even when PSA is below 4.
(The author is a senior IPS officer of West Bengal cadre. The views expressed are strictly personal)
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