Cancer is a worldwide problem. It kills 4.3 million people annually, 2.9 million of them in the developing world. The six most common tumours are carcinomas of the liver (hepatoma), bronchus, large gut, stomach, prostate, and breast. Although nearly 40% of malignant tumours can now be cured, if they are diagnosed sufficiently early, and treated appropriately, most of the patients who consult you will have such advanced disease that the help you can give them will be limited. Although a few tumours can be managed optimally with very limited facilities, many of the methods in this chapter are among the least cost- effective in this book. Nevertheless, there is always something you can do, even for the most hopeless patient; but you may have to turn to the next chapter on terminal care, to know what it is.
Your hospital may be a long way from any referral centre, so that if you don't diagnose and treat a patient with cancer, it is likely that that nobody else will. You may be unable to get prompt and reliable histological reports, or even any reports at all, and there will certainly be no one to examine frozen sections for you. You are unlikely to be able to refer anyone for radiotherapy, or even perhaps for expert surgery, so you will have to rely on simple surgery, and some of the easier and cheaper chemotheraputic regimes.
The sequence of steps with most patients is this:
Make the diagnosis of malignant disease clinically, and examine the patient carefully to assess its extent.
Confirm the diagnosis histologically (if you can) before you start treatment. If you are in doubt after taking a biopsy (which should include cutting the tissue across to inspect its cut surface), it is usually better to wait for a histological report, if this is possible. You should rarely, if ever, give a toxic treatment without knowing the histology.
Stage the tumour according to the criteria given here. Most malignant tumours have four stages, or sometimes five, some of which may be subdivided. The first two stages are usually curable, whereas the last two can usually only be palliated. For most tumours we give the prognosis for each stage, with various treatment methods.
Decide what is best for the patient. Can you treat him? Can someone else treat him? Can nobody treat him? Should you aim for cure or palliation? For example, chemotherapy can usually achieve a radical cure with Burkitt's lymphoma, and quite simple surgery can cure carcinomas of the skin and penis. Palliation may greatly help a patient with carcinoma of his prostate (oestrogen treatment), or a lymphoma (cytotoxic drugs), or carcinoma of his oesophagus (the insertion of a Celestin tube). Often, you can do little for him, because both surgery and chemotherapy may only prolong his suffering and that of his relatives.
Decide if you are going to refer him, or to treat or palliate him yourself. If a referral centre can do nothing for him, don't refer him. If private doctors cannot help him, persuade him not to waste his money on them.
When you make the difficult decision as to whom to treat and whom only to palliate, try, if you can, to base your decision on the response of the tumour, and not on his political influence, his social status, or on his ability to pay for the drugs. Unfortunately, in places where medicine has to be bought by individual patients, the poor are likely to get surgery, or nothing. Even so, make every effort to have some drugs available to treat such conditions as Burkitt's lymphoma and choriocarcinoma.
You will also have to decide where the treatment of tumours comes in your own priorities, and how much scarce money and skill should be devoted to less easily treated ones, when the more cost-effective calls on your resources are so great. The common useful tumours to treat are: squamous cell carcinoma, carcinoma of the penis, carcinoma of the breast (early), carcinoma of the prostate. The less common useful ones are: Burkitt's lymphoma, basal cell carcinoma, carcinoma of the large gut, invasive mole, and choriocarcinoma.
Occasionally, you will meet benign resectable tumours in places, such as the intestinal tract, where you normally expect malignant ones. So, remember their existence, investigate the patient as thoroughly as you can, and don't assume that a tumour is malignant, until you have proved it so.
Fig 32-1 ADVANCED UNTREATED NEOPLASIA. A, a very large giant cell tumour (26.7) of the mandible in a boy of 12. B, a large angiomatous sarcoma (32.8) of the blood vessels of the scalp. In the absence of adequate treatment this is what happens. Unfortunately, neither of these tumours are readily treatable by the methods described here. Both were seen by Bowesman in Ghana in the 1950s or earlier, but similar cases are still occasionally seen. After Charles Bowesman, ''Surgery and Clinical Pathology in the Tropics'. E, and S, Livingstone, with kind permission. ONCOLOGY IN A DISTRICT HOSPITAL. Here, as an example, are the 79 tumours seen in 1969 in Kamuli district hospital in Uganda: 15 hepatomas, all untreatable; 3 carcinomas of the oesophagus, all advanced; 6 carcinomas of the stomach, 4 of which were treated by palliative gastrectomy (not described here); 2 inoperable carcinomas of the rectum; 1 inoperable carcinoma of the pancreas; 19 carcinomas of the cervix including 1 early case treated by radical hysterectomy; 4 ovarian tumours, 2 treated surgically; 2 bladder cancers, both operable (exceptional); 6 carcinomas of the penis, all treated by partial amputation; 5 carcinomas of the prostate given hormone treatment; 1 operable thyroid tumour; 1 advanced cylindroma of the palate; 1 carcinoma of the submandibular glands, radically resected; 1 untreatable nasopharyngeal carcinoma; 5 squamous cell carcinomas, 3 of which were amputated; 1 Kaposi's sarcoma; 1 melanoma; 4 carcinomas of the breast, 3 treated by simple mastectomy; 2 Hodgkin's lymphomas; and 2 non-Hodgkin's lymphomas.
THE GENERAL METHOD FOR SOLID TUMOURS BASIC FACILITIES. For chemotherapy you will need an accurate scale to measure weight, and a height scale on the wall. From these you can work out a patient's surface area with Figure 58-6. You must also be able to measure a his blood urea, his haemoglobin, his total and differential white count (from which you will be able to work out his absolute granulocyte count), and if possible his platelets.
STAGING. Be thorough, and assess his tumour carefully according to the criteria in this chapter. This should always be possible, although you may need a general anaesthetic to do it (as with carcinoma of the cervix). Both the stage of a tumour, and often its histological grade, influence the prognosis, both with and without treatment.
TAKING A BIOPSY. If you are excising a lymph node, take the whole node if this is easy, but if it is not, a part of the node will do. If you are sending away a gland for histology, always cut it across. With experience you will be able to recognize the caseation of tuberculosis, and to distinguish hyperplasia from a tumour.
If you are taking tissue from an ulcer or a large mass, take it from the edge of the lesion, so that you include normal and abnormal tissue.
SENDING SPECIMENS. When you fix a tissue, place it in at least 5 times its volume of formol saline, which is 10% of formalin solution (itself a 30% solution of formalin in water) in 0.9% saline. Send small specimens in a screw-capped universal container in a wooden box made for the purpose. Or, fix the specimen first in formol saline for a few days, then wrap it in formol-saline-soaked cotton wool, pack this in a plastic bag, and send it in a cardboard box.
If you want to send a very large specimen for histology, such as an entire kidney, cut it so that the fixative can reach its interior, but leave the slices together at one edge, so that they can be put together again, and the shape of the specimen preserved. Fix the whole specimen in a bucket of formol saline. When it is fixed, seal it in a polythene bag, pack it in a cardboard box, and send it by hand.
CAUTION ! The danger in sending all pathological specimens is that they will leak in the post, contaminate the mail, and make you very unpopular with the post office!
THE KARNOFSKY PERFORMANCE SCALE Use this to assess the quality of life of the patients you treat. It is particularly important in managing patients having chemotherapy.
100%, the patient is normal, with no complications or evidence of disease.
90%, his activity is normal, but he has signs or symptoms of the disease.
80%, activity with effort.
70%, cares for himself, but is unable to work, or to undertake his normal activity.
60%, requires occasional help, but meets most of his personal needs.
50%, requires considerable help, and needs frequent nursing care.
40%, in bed or in a chair, and needs special care.
30%, severely disabled, and needs hospitalization.
20%, very sick.
Fig 32-1a BURKITT'S LYMPHOMA should be your first priority for chemotherapy. Note the swelling of both maxillae in child A. From Charles Bowesman, ''Surgery and Clinical Pathology in the Tropics', E. and S. Livingstone, with kind permission.