World Cancer Day 2016: Reducing Nigeria’s cancer burden

Poised to reduce the global burden of cancer, which kills about thrice the number of people who die of tuberculosis, HIV and malaria combined, the Union for International Cancer Control (UICC), established the World Cancer Day (WCD), on 4 February, 2008, to raise awareness and generate support for people living with the disease. From then on, WCD has been commemorated annually. However, the impact of the celebration seems quite limited, as the prevalence of the terminal disease continues to rise from year to year, and from border to border, claiming multitudes of lives all along.

One major issue that has been generally identified as a setback in the fight against cancer, especially in Nigeria, is inadequate medical facilities for the screening and treatment of the condition, as well as late presentation of patients to care centres.

This is why the theme for this year’s edition of WCD – “We can. I can” – is centred on deliberate actions by the government, corporate bodies and individuals, in reducing the disease burden in the country. The theme, which will last through 2018, implies that everyone can do something to inspire action, take action, prevent cancer, challenge perceptions, create healthy environments, improve access to cancer care, build a quality cancer workforce, mobilise networks to drive progress, shape policy change, make the case for investing in cancer control, and work together for increased impact.

This deliberate concerted effort is imperative because, according to the World Health Organisation (WHO), more than 70 per cent of cancer deaths occur in low- and middle-income countries. Although the risk of developing or dying from it is still higher in the developed world, early detection and prompt medical attention are key in its management.

According to the Medical Director, Pfizer Pharmaceutical Company, Dr Kodjo Soroh, cancer is on the rise, not only in Nigeria, but worldwide. As a result, doctors are still researching into its cure.

“The unfortunate aspect of cancer situation in Nigeria is not that doctors cannot treat it, but the cost of treatment and availability of medical equipment is grossly inadequate. Nigeria is not prepared for the Tsunami that is about to break in cancer. I did a little survey in the northwest of the country some two years ago. It was recorded in a teaching hospital that 30 new cases are reported every day. Cancer is killing Nigerians every day. The rate at which cancer is killing Nigerians is alarming. It is more than cases of deaths caused by malaria AIDS and Tuberculosis.

“The best way to get an idea on the prevalence is to go by the WHO statistics on cancer situation in Nigeria. The statistics is alarming. It says that per hour 30 Nigerians are dying of cancer. I say Nigeria is not prepared because, if you look at our National Health Insurance Scheme (NHIS) cancer is not covered. So, if you develop cancer now, you are on your own. How many radiotherapy units do you have in Nigeria and the specialists, how many oncologists? Early detection and diagnosis are important. Once these are delayed, it spreads and causes more damage. If you have money to go out, then the cost is on your head.”

He continued: “The best option anybody has is to prevent it. Government should invest more on the infrastructure and health personnel. Early screening and detection are important in cancer management or its prevention. Let us create more awareness by telling our women to do self breast examination, screen for cervical cancer that is even preventable by getting vaccinated.

“Let people disabuse their minds on a misconception that if they get female teenagers immunised against cervical cancer – that they are indirectly being prepared for promiscuity. Nigerians should move on. Get our women vaccinated against cervical cancer. There are some women who have been known to keep only a man and still come down with cervical cancer because pappiloma virus is the cause of that type of cancer. The statistics even have it that more married women may have cervical cancer than the unmarried.”

Explaining the development of cancer, the Medical Director, Triumph Medical Centre, Dr Deji Morenikeji, said cancer is the abnormal growth of body tissues in the cells and can affect any part of the body. “When a person is said to have developed cancer, it simply means the cells that are normal are fast growing into abnormal cells and distorting them. There is increase of awareness on cancer now. Government is actually playing a major role in cancer detection. It has a unit in the Ministry of Health dedicated to that.

“Unfortunately, in this part of the world people go late to the hospital. The treatment is not encouraging. If cancer is detected early, depending on the type of cancer, there is a five-year survival rate, and the rate is higher and impressive. Cancer drugs and treatments are expensive worldwide. Government is trying its best to contain the development of the disease, all things being equal, including not having its hereditary trait, and then its prevention, that is, its development is more individualistic.

On prevention, he said: “People should be mindful of their lifestyle. They should watch what they eat as what they consume plays important role on their well-being. They should exercise more and do away with sedentary lifestyle. They should do more health assessments, routine medical examinations.”

Statistics show that there are six most common cancers in Nigeria. They include:

• — Breast cancer
• — Cervix cancer
• — Prostate cancer
• — colorectal cancer
• — liver cancer and
• — NHL

 Breast cancer

Breast cancer is the commonest female cancer and studies have indicated increase in the relative frequency ratio; moving from number two or three to the number one cancer in both sexes..This increase has been attributed to increase awareness and presentation for screening. Majority of breast cancers occur in pre-menopausal women with the peak age in the 5th decade…

About 80-85 per cent still present in advance stage III with attendant poor outcome. In Nigerian studies, only 25-50 per cent of the tumours are reported to be oestrogen/progesterone receptor positive, which is the basis for hormonal treatment.

 Causes of breast cancer

When you’re told that you have breast cancer, it’s natural to wonder what may have caused the disease. But no one knows the exact causes of breast cancer. Doctors seldom know why one woman develops breast cancer and another doesn’t, and most women who have breast cancer will never be able to pinpoint an exact cause. What we do know is that breast cancer is always caused by damage to a cell’s DNA.

Risk factors for breast cancer

• — Female gender
• — increasing age
• — Maternal relative with breast cancer
• — Abnormal genes (BRCA 1, BRCA2 genes)
• — Nulliparity
• — Late age at first pregnancy and longer reproductive span (early menarche<12yrs, late menopause>50yrs).

Others are

• obesity
• — Increased dietary fat & alcohol intake
• — Cigarette smoking
• — Previous breast lesion with atypical changes
• — Previous breast cancer.

Male breast cancer

In Nigeria, this represents 3.7-8.6 per cent of all breast cancers. This is higher than the 1 per cent recorded from other parts of the world. The higher figures in Nigeria may be due to small sample size, since the data are mainly-hospital based. The peak age incidence is 40-49 years, similar to that of female cancer. Majority are invasive ductal carcinoma. It is characterised by late presentation at advanced stage with attendant poor prognosis.

Diagnosis of breast cancer

Breast cancer is sometimes found after symptoms appear, but many women with early breast cancer have no symptoms. This is why getting the recommended screening tests before any symptoms develop is so important.

If you think you have any signs or symptoms that might mean breast cancer, be sure to see your doctor as soon as possible. Your doctor will ask you questions about your symptoms, any other health problems, and possible risk factors for benign breast conditions or breast cancer.

If breast symptoms and/or the results of your physical exam suggest breast cancer might be present, more tests will probably be done. These might include imaging tests, looking at samples of nipple discharge, or doing biopsies of suspicious areas.

 Mammograms

A mammogram is an x-ray of the breast. Screening mammograms are used to look for breast disease in women who have no signs or symptoms of a breast problem. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast.

For a mammogram, the breast is pressed between two plates to flatten and spread the tissue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. If your diagnostic mammogram shows that the abnormal area is more suspicious for cancer, a biopsy will be needed to tell if it is cancer.

Even if the mammograms show no tumour, if you or your doctor can feel a lump, a biopsy is usually needed to make sure it isn’t cancer. One exception would be if an ultrasound exam finds that the lump is a simple cyst (a fluid-filled sac), which is very unlikely to be cancerous.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image. For breast MRI to look for cancer, a contrast liquid called gadolinium is injected into a vein before or during the scan to show details better.

MRI scans can take a long time “ often up to an hour. For a breast MRI, you have to lie inside a narrow tube, face down on a platform specially designed for the procedure. The platform has openings for each breast that allow them to be imaged without compression. The platform contains the sensors needed to capture the MRI image. It is important to remain very still throughout the exam.

 Prevention of breast cancer

The following tips are essential in preventing breast cancer

• Regular breast examination
• Changing lifestyle or eating habits.
• Avoiding things known to cause cancer.
• Taking medicine to treat a precancerous condition or to keep cancer from starting.

 Cervical cancer

Cervical cancer occurs when abnormal cells on the cervix grow out of control. The cervix is the lower part of the uterus that opens into the vagina. Cervical cancer can often be successfully treated when it’s found early. It is usually found at a very early stage through a Pap test.

Cervical cancer is the second most common cancer in Nigerian women and the most common female genital cancer constituting a major cause of mortality among Nigerian females in their most productive years. It was the commonest cancer reported from Ibadan, Eruwa, Zaria, Jos, Benin and Calabar and in the early years, second to breast in Enugu and Ife-Ijesha , as indicated by a study conducted by Professor Fatimah Abdulkareem of the College of Medicine, University of Lagos.

Recent data shows that it has however been overtaken by breast cancer – except in Kano where it was reported as the most common cancer in both sexes. In Jos, it is the most common female cancer.

Human papillomavirus (HPV) is a necessary cause of cervical cancer being present in 99.9 per cent of cases. In a study of 233 cases of cervical cancer from Lagos, HPV 16 and 18 were present in 65.2 per cent.. This supports data that effective vaccination against these two types will reduce the cervical burden in Nigeria.

You can get HPV by having sexual contact with someone who has it. There are many types of the HPV virus. Not all types of HPV cause cervical cancer. Some of them cause genital warts, but other types may not cause any symptoms.

 Symptoms of cervical cancer may include:

• Bleeding from the vagina that is not normal, such as bleeding between menstrual periods, after sex, or after menopause.
• Pain in the lower belly or pelvis.
• Pain during sex.
• Vaginal discharge that isn’t normal.

The treatment for most stages of cervical cancer includes:

• Surgery, such as a hysterectomy and removal of pelvic lymph nodes with or without removal of both ovaries and fallopian tubes.
• Chemotherapy.
• Radiation therapy.

 Prevention of cervical cancer

The Pap test is the best way to find cervical cell changes that can lead to cervical cancer. Regular Pap tests almost always show these cell changes before they turn into cancer. It’s important to follow up with your doctor after any abnormal Pap test result so you can treat abnormal cell changes. This may help prevent cervical cancer.

If you are age 26 or younger, you can get the HPV vaccine, which protects against two types of HPV that cause most cases of cervical cancer.

Prostate cancer

The prostate is a gland that is a part of the male reproductive system that wraps around the male urethra at its exit from the bladder. Common problems are BPH (Benign Prostatic Hyperplasia), acute and chronic bacterial prostatitis and chronic prostatitis (non-bacterial)

Prostate cancer is common in men over 50, especially those who eat fatty food and/or have a father or brother with prostate cancer. It is the most common cancer in Nigerian males, having overtaken liver cancer. It accounts for 6.1-19.5 per cent of all cancers and the incidence is increasing.. Current data from most parts of the country show it to be the 3rd most common cancer, except in Calabar where a very high figure was recorded for prostate cancer as the most common in both sexes accounting for 34.7 per cent of all cancers.

Compared to African-American men, Nigerian men are 10 times more likely to have prostate cancer and 3.5 times more likely to die from it. Environmental and most importantly, genetic factors have been incriminated as the reason for the geographic differences in incidence.

Risk factors for prostate cancer include:

• — race
• — age above 40years
• — positive family history
• — high fat diet and
• — high serum androgens levels; the latter being most consistent.

 Symptoms of prostate cancer

Symptoms of prostate problems (and prostate cancer) include urinary problems (little or no urine output, difficulty starting (straining) or stopping the urine stream, frequent urination, dribbling, pain or burning during urination), erectile dysfunction, painful ejaculation, blood in urine or semen and/or deep back, hip, pelvic or abdominal pain. Other symptoms may include weight loss, bone pain and lower extremity swelling.

Prostate cancer is definitively diagnosed by tissue biopsy. Initial studies may include a rectal exam, ultrasound and PSA (prostate-specific antigen) levels.

Treatments for prostate cancer may include surveillance, surgery, radiation therapy, and hormone therapy. PSA testing is considered to be yearly PSA tests; not all agree this should be done.

Identifying prostate problems early is a way to reduce future prostate problems.

 Diagnosis of prostate cancer

The diagnosis of prostate cancer mostly involves a combination of three tests:

• Digital rectal examination: As part of a physical examination, your doctor inserts a gloved and lubricated finger into your rectum and feels toward the front of your body. The prostate gland is a walnut or larger-sized gland immediately in front of the rectum, and beneath your bladder. The back portion of prostate gland can be felt in this manner. Findings on this exam are compared to notes about the patient’s prior digital rectal examinations.

The exam is usually brief, and most find it uncomfortable due to the pressure used to adequately examine the prostate gland. Findings such as abnormal size, lumps, or nodules, may indicate prostate cancer.

This examination should be part of an annual physical in all men over 50 years of age to note changes in the prostate. In men with a family history of prostate cancer, or in African American men exams should begin at 40 years of age.

• Prostate specific antigen (PSA) blood test: The PSA blood test measures the level of a protein found in the blood that is produced by the prostate gland and helps keep semen in liquid form. The PSA test can indicate an increased likelihood of prostate cancer if the PSA is at an increased or elevated level, but it does not provide a definitive diagnosis. Prostate cancer can be found in patients with a low PSA level but this occurs less than 20 per cent of the time.

If the PSA level is elevated (levels can depend upon your age, on the size of your prostate gland on examination, certain medications you may be taking, or recent sexual activity), further testing may be needed to rule out prostate cancer. PSA measurements are often tracked over time to look for evidence of a change. The amount of time it takes for the PSA level to increase is referred to as PSA velocity. A PSA doubling time can be also tracked in this fashion. PSA velocity and PSA doubling time can help your doctor determine whether prostate cancer may be present.

The presence of an abnormal result on digital rectal examination, or a new or progressive abnormality in a PSA test may lead to a referral to a surgeon who specialises in diseases of the urinary system (a urologist) who may perform further testing, such as a biopsy of the prostate gland.

 

• Prostate biopsy: A biopsy refers to a procedure which involves taking of a sample from a tissue in the body. Prostate cancer is only definitively diagnosed by finding cancer cells on a biopsy sample taken from the prostate gland. The urologist may have you stop medications such as blood thinners before the biopsy.

On the day of the biopsy, the doctor will apply a local anaesthetic by injection or topically as a gel inside the rectum over the area of the prostate gland. An ultrasound probe is then placed in the rectum. This device uses sound waves to take a picture of the prostate gland and helps guide the biopsy device. The device used is a spring-loaded needle that allows the urologist to extract cores from the prostate gland. Usually 12 cores are obtained, six from each side. Two cores are taken from the upper, middle, and lower portions of the prostate gland. The cores are submitted for analysis to a pathologist (a doctor who specializes in examining tissues to make a diagnosis). Results may take several days.

A biopsy procedure is usually uncomplicated, with just some numbness, pain, or tenderness in the area for a short time afterwards. Occasionally, a patient has some bleeding in the urine after the procedure. Rarely, the patient may develop an infection after a biopsy procedure, or be unable to urinate. The patient will be advised to call and consult a doctor if such problems occur.

 Prostate cancer biopsy results

The result of the pathologist’s analysis of the biopsy cores under the microscope is the only way to diagnose prostate cancer.

Treatment of prostate cancer

Treatment options for prostate cancer are many, and while this is an advantage in that prostate cancer is such a common disease in men, it can also be a cause of great confusion. The following overview presents some information about these options, but it is not a complete explanation of any of these.

 Surgery

The removal of the entire prostate gland and the attached seminal vesicles is referred to as a radical prostatectomy. This is usually done through an incision or incisions made over the front of the lower abdominal wall, with the procedure taking place behind the pubic bones at the front of the pelvis (a retropubic approach). Today the main choice is between a standard open radical prostatectomy and the use of a robotic system for performance of the procedure through smaller incisions. The former allows the surgeon to feel the tissues and make the cuts themselves. The latter uses an operating system robot, which the surgeon guides. The former takes longer to recover from, and has more risk of blood loss associated with it. The latter results in a more rapid recovery and less blood loss generally.

Intact pelvic nerve bundles on either side of the prostate in the pelvis are essential for a man to be able to have an erection. Impotence – or the inability to have and sustain an erection of a quality sufficient for successful intercourse – can occur after this operation. The likelihood of impotence is primarily dependent on whether or not the necessary nerves can be preserved during surgery, AND the patient’s true preoperative ability to still have an erection. Nerve-sparing surgical technique is desirable and the surgeon should plan to do this, if possible. These important pelvic nerve bundles may need to be sacrificed if they are too close to or are involved with the cancer. The objective of the surgery is to cure the patient of the prostate cancer with the least number of problems afterward as possible, but the performance of a potentially curative procedure must remain the primary objective of the surgeon.

The radical prostatectomy involves the removal of a portion of the urethra. The urethra is the tube that runs from the bladder to the outside through the penis. It runs through the prostate gland. The procedure can disrupt the sphincter or valve, which controls urine flow from the bladder. The surgeon reconnects the urethra to the bladder after the prostate is out. The more careful and experienced the surgeon, the less the risk of long-term inability to control the flow of urine (incontinence).

The risks of an operation lasting several hours also remains substantial and include heart problems, blood loss, as well as a risk of infection, blood clots, and rarely, death. Such operations are appropriate for patients whose cancer appears to be confined to the prostate gland.

 Radiation therapy

Radiation therapy involves potentially curative treatment using machines that generate and administer controlled, invisible beams of energy known as radiation. This is called external beam radiation therapy (EBRT). It also can be done using radioactive sources, or seeds, implanted permanently, or higher energy sources placed temporarily into the body. This technique is called brachytherapy.

An X-ray machine uses a low energy radiation beam to take a picture of a portion of the body. Radiation therapy machines put out high energy beams that can be focused very precisely to deliver treatment to a site. The radiation does not “burn out” the cancer, but damages the cells’ DNA, which causes the cancer cells to die. This process can take some time to occur after the radiation treatments have been given.

The radiation passes directly through the tissues in EBRT. Radiation treatment used today delivers very little energy to normal tissues. It just passes through. Most of the energy is able to be focused and delivered directly to the area of the prostate gland containing cancer. This process minimises damage to healthy tissue.

Radiation therapy to the prostate gland by external beam technique may cause fatigue and bladder and/or rectal irritation. These effects are usually temporary but may recur or persist long after treatments are finished. Radiation damage to adjacent tissues can cause skin irritation, and local hair loss. Delayed onset of impotence can occur after radiation therapy due to its effect on normal tissues including nerves adjacent to the prostate. Radiation therapy may be given alone or in combination with hormonal therapy which can also shrink up the prostate gland thereby reducing the size of the radiation area or field that needs to be treated.

A recently popular technique of EBRT is called proton beam radiation, which can theoretically more closely focus on the area being treated. Proton beam radiation therapy is more expensive. Its side effects presently appear similar to those discussed for standard radiation therapy. Studies comparing the effectiveness and overall results of conventional radiation therapy versus proton beam therapy have not been completed yet.

EBRT is appropriate for men who are candidates for radical prostatectomy but do not wish to undergo the surgery. It is also used to shrink tumours and reduce pain in areas where metastatic prostate cancer is damaging bone, or is pressing on important structures including the spinal cord.

Note that radiation therapy can be performed after radical prostatectomy if prostate cancer recurs in the region where the prostate was, and can potentially cure a locally recurrent prostate cancer if it has not spread beyond the area, after radiation therapy has been given. If radiation fails to control the cancer, surgery is difficult – if not impossible – to perform due to scar tissue which develops in the area.

Colorectal cancer

Most colorectal cancers arise from adenomatous polyps. Such polyps are comprised of excess numbers of both normal and abnormal appearing cells in the glands covering the inner wall of the colon. Over time, these abnormal growths enlarge and ultimately degenerate to become adenocarcinomas.

People with certain genetic abnormalities develop what are known as familial adenomatous polyposis syndromes. Such people have a greater-than-normal risk of colorectal cancer. In these conditions, numerous adenomatous polyps develop in the colon, ultimately leading to colon cancer.

Colorectal carcinoma is the commonest malignancy of the gastrointestinal tract worldwide. Previous studies had shown it to be a rare disease in Nigeria representing 3-6 per cent of all malignant tumours in most studies. .It accounts for 10-50 per cd of all GIT malignancies in Nigeria. Peak incidence is 60-70 years; mean age in Lagos is 50.7yrs..When it occurs in the young, associated with polyposis syndrome or ulcerative colitis should be suspected.

Contrary to previous report which showed it to be rare, recent report shows the incidence to be increasing. An 81 per cent increase over a period of two decades was reported from Ibadan. .A recent study from Lagos & Sagamu showed similar trend with an increase in annual frequency of this cancer from 14 cases per annum to 32.3 cases per annum. .The low incidence in Nigerians was attributed to fibre rich diet which is common practice and rarity of the familial polyposis syndrome and IBD.

Recent urbanisation/civilisation has resulted in upsurge of confectionary food outlets in major cities resulting in many Nigerians changing their dietary habit from a fibre rich diet, which was common practice to a highly refined carbohydrate and fat diet.

 Colon cancer symptoms

Cancer of the colon and rectum can exhibit itself in several ways. If you have any of these symptoms, seek immediate medical help. You may notice bleeding from your rectum or blood mixed with your stool.

• People commonly attribute all rectal bleeding to haemorrhoids, thus preventing early diagnosis owing to lack of concern over “bleeding haemorrhoids.” New onset of bright red blood in the stool always deserves an evaluation. Blood in the stool may be less evident, and is sometimes invisible, or causes a black or tarry stool.
• Rectal bleeding may be hidden and chronic and may only show up as an iron deficiency.
• It may be associated with fatigue and pale skin due to the anaemia.
• It usually, but not always, can be detected through a fecal occult (hidden) blood test, in which samples of stool are submitted to a lab for detection of blood.
• If the tumour gets large enough, it may completely or partially block your colon. You may notice the following symptoms of bowel obstruction:
• Abdominal distension: Your belly sticks out more than it did before without weight gain.
• Abdominal pain: This is rare in colon cancer. One cause is tearing (perforation) of the bowel. Leaking of bowel contents into the pelvis can cause inflammation (peritonitis) and infection.
• Unexplained, persistent nausea or vomiting
• Unexplained weight loss
• Change in frequency or character of stool (bowel movements)
• Small-calibre (narrow) or ribbon-like stools
• Sensation of incomplete evacuation after a bowel movement
• Rectal pain: Pain rarely occurs with colon cancer and usually indicates a bulky tumour in the rectum that may invade surrounding tissue.

Other factors that may affect your risk of developing a colon cancer:

• Diet: Whether diet plays a role in developing colon cancer remains under debate. The belief that a high-fibre, low-fat diet could help prevent colon cancer has been questioned. Studies do indicate that exercise and a diet rich in fruits and vegetables can help prevent colon cancer.
• Obesity: Obesity has been identified as a risk factor for colon cancer.
• Smoking: Cigarette smoking has been definitely linked to a higher risk for colon cancer.
• Drug effects: Recent studies have suggested postmenopausal hormone, oestrogen replacement therapy may reduce colorectal cancer risk by one third. Patients with a certain gene which codes for high levels of a hormone called 15-PGDH may have their risk of colorectal cancer reduced by one half with the use of aspirin

Also at high risk for developing colon cancers are people with any of the following:

• Ulcerative colitis or Crohn’s colitis (Crohn’s disease)
• Breast, uterine, or ovarian cancer now or in the past
• A family history of colon cancer

The risk of colon cancer increases two to three times for people with a first-degree relative (parent or sibling) with colon cancer. The risk increases further if you have more than one affected family member, especially if the cancer was diagnosed at a young age.

Exams and tests

You may have a test called a colonoscopy. This is a test that allows a specialist in digestive diseases (a gastroenterologist) to look at the inside of your colon. This test looks for polyps, tumours, or other abnormalities.

Colonoscopy is an endoscopic test. This means that a thin, flexible plastic tube with a tiny camera on the end will be inserted into your colon via your anus. As the tube is advanced further into your colon, the camera sends images of the inside of your colon to a video monitor.

Colonoscopy is usually done with sedation and is not an uncomfortable test for most people. You will first be given a laxative solution to drink that will clear most of the faecal matter from your bowel. You will be allowed nothing to eat for a short period before the test and a liquid diet only for a day before the test.

Flexible sigmoidoscopy is similar to colonoscopy but does not go as far into the colon. It uses a shorter endoscope to examine the rectum, sigmoid (lower) colon, and most of the left colon.

CT colonography is another way to examine the colon. Again, the stool must be cleared from the colon before the examination. Colonoscopy allows sample to be taken (biopsies) if an abnormality is found. Colonography does not allow that, as there is no direct visualisation of the interior of the colon.

This test highlights tumours and certain other abnormalities in the colon and rectum.

Other types of contrast enemas are available.

Air-contrast barium enema frequently detects malignant tumours, but it is not as effective in detecting small tumours or those far up in your colon.

If a tumour is identified in the colon or rectum by a biopsy performed during a sigmoid or colonoscopy, you will

Medical treatment

The primary treatment of colon cancer is to surgically remove part of your colon. Suggestive polyps, if few in number, may be removed during colonoscopy. Chemotherapy after surgery can improve your likelihood of being cured if your colon cancer has spread to nearby lymph nodes.

Radiation treatment after surgery does not improve cure rates in people with colon cancer, but it is important for people with rectal cancer. Given before surgery, radiation may reduce tumour size. This can improve the chances that the tumour will be removed successfully. Radiation before surgery also appears to reduce the risk of the cancer coming back after treatment.

Radiation plus chemotherapy before or after surgery for rectal cancer can improve the likelihood that the treatment will be curative

 

Liver cancer

Primary liver cancer is a condition that happens when normal cells in the liver become abnormal in appearance and behaviour. The cancer cells can then become destructive to adjacent normal tissues, and can spread both to other areas of the liver and to organs outside the liver.

Malignant or cancerous cells that develop in the normal cells of the liver (hepatocytes) are called hepatocellular carcinoma. A cancer that arises in the ducts of the liver is called cholangiocarcinoma.

What is metastatic liver cancer?

Metastatic cancer is cancer that has spread from the place where it first started (the primary site) to another place in the body (secondary site). Metastatic cancer in the liver is a condition in which cancer from other organs has spread through the bloodstream to the liver. Here the liver cells are not what have become cancerous. The liver has become the site to which the cancer that started elsewhere has spread.

Metastatic cancer has the same name and same type of cancer cells as the original cancer. The most common cancers that spread to the liver are breast, colon, bladder, kidney, ovary, pancreas, stomach, uterus, breast, and lungs.

Metastatic liver cancer is a rare condition that occurs when cancer originates in the liver (primary) and spreads to other organs (secondary) in the body.

Some people with metastatic tumours do not have symptoms. Their metastases are found by x-rays or other tests. Enlargement of the liver or jaundice (yellowing of the skin) can indicate cancer has spread to the liver.

Liver cancer is the most common cause of cancer death in Nigeria and the most common liver malignancy in Nigeria is hepatocellular carcinoma (HCC). Data from various parts of Nigeria show that it accounts for between 1.6 per cent – 7.2 per cent of all cancers in both sexes and represent the 2nd or 3rd most common cancer in males.

HCC was earlier reported to be the most common male cancer until recently when it was overtaken by prostate cancer.   It is the most common cause of liver disease in Nigeria accounting for between 29.3 per cent – 64 per cent of all liver biopsies in several studies. The peak age incidence has been found to be a decade earlier than for liver cirrhosis and hepatitis. A significant number of cases occur in association with liver cirrhosis.

Most people who get liver cancer get it in the setting of chronic liver disease (long-term liver damage called cirrhosis), which scars the liver and increases the risk for liver cancer. Conditions that cause cirrhosis are alcohol use/abuse, hepatitis B, and hepatitis C.

The causes of liver cancer may be linked to environmental, dietary, or lifestyle factors. For example, in November 2014, researchers at the University of California, San Diego School of Medicine, found that long-term exposure to triclosan, a common ingredient in soaps and detergents, causes liver fibrosis and cancer in laboratory mice. Although triclosan has not been proven to cause human liver cancer, it is currently under scrutiny by the FDA to determine whether it has negative health impacts.

According to the American Cancer Society, “The stage of cancer is a description of how widespread it is. The stage of a liver cancer is one of the most important factors in considering treatment options. A staging system is a standard way for the cancer care team to sum up information about how far a cancer has spread. Doctors use staging systems to get an idea about a patient’s prognosis (outlook) and to help determine the most appropriate treatment. There are several staging systems for liver cancer, and not all doctors use the same system.”

Liver biopsy as well as imaging studies help in classifying liver cancer stages as per the American Joint Committee on Cancer (AJCC) TNM system, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Cancer of the Liver Italian Programme (CLIP) system, or the Okuda system.

Treatment of liver cancer

The treatment chosen depends upon how much the cancer has spread and the general health of the liver. For example, the extent of cirrhosis (scarring) of the liver can determine the treatment options for the cancer. Similarly, the spread and extent of spread of cancer beyond the liver tissue plays an important part in the types of treatment options that may be most effective.

• Surgery: Liver cancer can be treated sometimes with surgery to remove the part of liver with cancer. Surgical options are reserved for smaller sizes of cancer tumors. Complications from surgery may include bleeding (which can be severe), infection, pneumonia, or side effects of anaesthesia.

• Liver transplant: The doctor replaces the cancerous liver with a healthy liver from another person. It is usually used in very small unresectable (not able to be removed) liver tumours in patients with advanced cirrhosis. Liver transplant surgery may have the same complications as noted above for surgery. Also, complications from medications related to a liver transplant may include possible rejection of the liver transplant, infection due to suppression of the immune system, high blood pressure, high cholesterol, diabetes, weakening of the kidneys and bones, and an increase in body hair.

• Ablation therapy: This is a procedure that can kill cancer cells in the liver without any surgery. The doctor can kill cancer cells using heat, laser, or by injecting a special alcohol or acid directly into the cancer. This technique may be used in palliative care when the cancer is unresectable.

• Embolisation: Blocking the blood supply to the cancer can be done using a procedure called embolisation. This technique uses a catheter to inject particles or beads that can block blood vessels that feed the cancer. Starving the cancer of the blood supply prevents the growth of the cancer. This technique is usually used on patients with large liver cancer for palliation. Complications of embolisation include fever, abdominal pain, nausea, and vomiting.

• Radiation therapy: Radiation uses high-energy rays directed to the cancer to kill cancer cells. Normal liver cells are also very sensitive to radiation. Complications of radiation therapy include skin irritation near the treatment site, fatigue, nausea, and vomiting.

• Chemotherapy: Chemotherapy uses a medicine that kills cancer cells. The medicine can be given by mouth or by injecting it into a vein or artery feeding the liver. People can have a variety of side effects from chemotherapy, depending on the medications used and the patient’s individual response. Complications of chemotherapy include fatigue, easy bruising, hair loss, nausea and vomiting, swollen legs, diarrhoea, and mouth sores. These side effects are usually temporary.

 Prognosis of liver cancer

The prognosis for liver cancer depends on multiple factors such as the size of the cancer, the number of lesions, the presence of spread beyond the liver, the health of the surrounding liver tissue, and the general health of the patient. Life expectancy depends on many factors that determines whether a cancer is curable.

The American Cancer Society states that the overall 5-year survival rate for all stages of liver cancer is 15 per cent. One of the reasons for this low survival rate is that many people with liver cancer also have other underlying medical conditions such as cirrhosis. However, the 5-year survival rate can vary, depending on how much the liver cancer has spread.

If the cancer is localised (confined to the liver), the 5-year survival rate is 28 per cent; if it is regional (has grown into nearby organs), the 5-year survival rate is 7 per cent. Once the cancer is distant (spread to distant organs or tissues), the survival time is as low as 2 years.

Survival rate can also be affected by the available treatments. Liver cancers that can be surgically removed have an improved 5-year survival rate of over 50 per cent. If caught in the earliest stages, and the liver is transplanted, the 5-year survival rate can be as high as 70 per cent.

 References:

Report compiled by Temitope Obayendo, with additional information from Professor’s Fatimah Abdulkareem’s work on: “Epidemiology & Incidence of Common Cancers in Nigeria”; American Cancer Society; WHO; National cancer institute; thenationonlineng; and emedicinehealth