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October- Breast Cancer awareness month!

Breast cancer is the most common cancer among women in the India and around the world. As per the reports, one in 28 women is likely to develop breast cancer during her lifetime in India. So, no matter from where you belong or where you live, breast cancer may touch your life.

Early detection has led to improved survival for women of all ages and races.

Breast cancer most commonly begins in the duct cells of the breast and can invade surrounding tissues or spread to other areas of the body. When cancer cells travel to other parts of the body and begin damaging other tissues and organs, the process is called metastasis.

Breast cancer can be:

  • Ductal carcinoma: It is of the most common type and begins in the milk duct.
  • Lobular carcinoma: It starts in the lobules.

Symptoms of the breast cancer

  • Area of thickened tissue in the breast, or a lump in the breast or armpit.
  • A rash around or on one of the nipples.
  • Vague pain in the breast that doesn’t change with the monthly cycle.
  • Redness on the skin of the breast.
  • A change in shape or size of the breast.
  • Scaling of the skin on the breast or nipple.

Since, October is the Breast Cancer Awareness month! So, have you self examined your breasts? Have you got your mammogram done? Here are the screening recommendations.

  • Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.
  • Women age 45 to 54 should get mammograms every year.
  • Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening.

Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.

How to treat breast cancer?
Your treating physician decides what are the best options for you. It depends on the size and stage of cancer at initial diagnosis. On a suspicion of cancer or to rule out same, you will be advised a `fine needle aspiration (some call it biopsy) cytology where a few cells are sucked out by a thin injection needle by a pathologist (doctor trained in lab medicine) and examined by the pathologist under the microscope. Depending upon the results of this test, future treatment shall be decided. A surgery is usually the first step to remove the tumor. Extensiveness of the surgery will again depend on the size of the tumor. The tissue removed is again sent to a pathologists who further can confirm the cancer, type and grade it. She/he also does a test called ER, PR, Her2Neu test on the tissue received. This will provide information of the hormone responsiveness of the tumor and help to choose the drugs required for treatment.

The patient may need systemic therapies which can reach cancer cells almost anywhere in the body. Chemotherapy, Hormone therapy and Targeted therapy ( decided on lab test on tissue provided by pathologist) are examples of these.

Who can treat it?
You will be treated under a team of doctor each of which will contribute to success of your treatment.
-Pathologist who will confirm, type and grade your cancer. This will guide the treating doctors on treatment modalities. You also need the pathologist to check your blood counts for side effects of chemotherapy and to diagnose a recurrence anywhere.

  • A breast surgeon or surgical oncologist will do the primary surgery with removal of cancer tumor.
  • A radiation oncologist, in case radiation required.
  • A medical oncologist who will prescribe the drugs and chemotherapy.
  • A plastic surgeon who will look into cosmetic aspects of the surgery as well as further reconstruction of the breast tissue.

Skin Cancer

What are skin cancers?

They are abnormal growths of cells which form components of our skin. Most commonly are:
-Squamous cell carcinoma.
-Basal cell carcinoma.
-Melanoma.
The remaining types are rare and constitute less than 1% of skin cancers. Fortunately if detected and treated early, most skin cancers do well. The worst outlook amongst those enlisted is usually for melanomas which look like moles or arise from a mole initially.

What are the risk factors for skin cancers?

Most important is exposure to UV radiation. Factors which predispose to skin damage by UV radiation with further development of skin cancer are:

  • Those patients who have had skin cancer before.
  • Have many moles, especially large or irregular ones, itchy ones.
  • Family history of melanoma or skin cancer
  • Light skin and light eyes.
  • Spend a lot of time outdoors.
  • Living in high altitudes/tropical and subtropical countries.
  • Sudden exposure to sunlight after predominant indoor living.
  • People with freckles/skin burns due to exposure to sun.
  • Certain autoimmune diseases like SLE/certain inherited conditions like Gorlin Syndrome or xeroderma pigmentosum.
  • Organ transplants.
  • Have a lower immune status due to HIV infection or an autoimmune disease of the skin. People who take medications for a disease which decreases immunity or take drugs to increase sensitivity to UV light like as that for treatment of psoriasis

How does one protect themselves form UV radiation?

Avoid prolonged exposure to sun especially from 10 am to 4 pm, wear eye shades, use sunscreens, wear hats (2-3inches rim), keep your skin covered. Dark clothes with tightly woven fabric protect you better. UV radiation is present on cloudy days too and is infact maximum in spring. Most precaution needs to be taken when on snow, beach (sand) and in water because all three reflect light and increase the UV radiation. Most deceptive is under water when you maybe feeling cool but are not protected from UV radiation. If you are likely to spend a lot of time outdoors on a vacation you could use an app now available in smartphones which show the UV index for that area !

How do I use sunscreen?

First and foremost sunscreen never gives you complete protection; not better that clothing or preferring the shade. Its only a filter and while selecting one check the labels. It should protect you from both UVA and UVB (broad spectrum). It should be with an SPF of 30+ atleast.

What is SPF?

The SPF number is the level of protection you get against UVB rays which are the most harmful. So a higher SPF means better protection against UVB rays. Unless specifically mentioned as broad spectrum sunscreen, these do not protect against UVA. SPF 15 screens out about 93% of UVB rays, SPF 50 about 98%. But no sunscreen protects you completely even if waterproof. When you apply an SPF 30 sunscreen correctly, you get the equivalent of 1 minute of UVB rays for each 30 minutes you spend in the sun. So, 1 hour in the sun wearing SPF 30 sunscreen is the same as spending 2 minutes totally unprotected!

Sunglasses

Before you buy a pair, check the labels for UV protection. Ideal ones should block 99-100% of both UVA and UVB rays. Labels saying`meets ANSI UV requirements’ or UV absorption upto 400nm block 99% of UV light. Those labelled `cosmetic` block about 70% UV rays. If there is no label, don’t be sure of UV protection. Always look for the ANSI label. And darker colors do not mean more protection!

Sun exposure and vitD

Most of the Vit D we need comes from sun exposure. So how much is good and not so good. Presently hard to tell although research is on. The amount of Vit D that your body makes depends on your age, your skin color and the amount of sunlight you are exposed to. The latest recommendations are to get the needed Vit D from your diet and supplements rather than the sun and these are more reliable ways of getting the Vitamin.

Skin examination.

Get your skin examined regularly by a doc; it could part of your regular medical exam. Do a skin examination yourself in a well lit room in front of a full length mirror once a month. Show the “hard to see“ areas, like the back of scalp etc to your spouse or any dear one. Check all your moles freckles, blemishes and if there are any new changes in them. Most worrying symptoms are a sore that does not heal, redness or bleeding or itching or increase in size of a mole. Change in sensation/ pain in a mole or spread of color pigment into the surrounding skin is usually of concern. Get to your doctor if anything comes up which concerns you. A fast growing mole/itchy lesion is usually biopsied by a dermatologist/ surgeon and seen by a pathologist under a microscope to look for any cancerous changes.

Healthy diet

Last but not the least eat nutritious healthy food known for having antioxidants and all the essential vitamins to keep your skin healthy, glowing and keep that sun out to stay clear of skin cancer!

What are the symptoms and recommended tests for Obesity?

Obesity can be thought of as a chronic disease which can have a negative effect on the body. Some medical problems like hormone imbalances & neurotransmitter deficiencies contribute to obesity. It can significantly shorten an individual’s life span and people with morbid obesity are at a risk of developing a number of serious problems. As such, obesity can be considered as one of the greatest public health challenges of our time. Several causes for obesity and factors involved are as follows:

  • If an individual takes more calories than they can burn, they will gain weight.
  • Physical inactivity can be strongly correlated with weight gain among people.
  • Genetic factors may cause the changes in appetite and fat metabolism that lead to obesity.
  • Some people have the habit of eating more during different emotions like, stress, boredom, sadness and anger. This can also result into getting obese.

Health problems associated with Obesity

  • Sleep apnea
  • Certain types of cancers due hormonal associations
  • Heart disease
  • Depression ( can be a cause and effect)
  • Type 2 diabetes Melli ’tis
  • Liver disease
  • High blood pressure
  • Joint disease

Recommended tests

Health history of the patient – A physician reviews the patient’s weight history, exercise habits, weight-loss efforts and eating patterns.
A physical exam – It includes measuring the height of the person, mapping heart rate, blood pressure levels and body temperature.
Body Mass Index – It helps in determining a person’s overall health risk and the level of the obesity.
Blood tests – Some of the common blood tests include a lipid profile including cholesterol test, liver function test, a fasting glucose and a thyroid test. Hormonal studies maybe needed in addition.

Treatment

Everyone wants to be fit and maintain a good health. For patients with diabetes, a consult with health professionals to understand and make changes in their eating habits is wise. The treatment for an individual depends upon the level of their obesity and overall health. Your physician can advise you, if any medical treatment is required. Eat more fiber and proteins and less fat and carbs. Use olive oil for cooking. Take in calories as per your BMI and burning you do in a day. Eat small light frequent meals rather than v large fatty few meals.

Advise – Burning fat with exercise deals with emotional stress, and exhilarates your mind and body so we would advise you to maintain a healthy body weight, eat a well-balanced diet and exercise regularly.

What do you need to know about high CRP?

CRP is a substance produced by the liver in response to inflammation. C Reactive Protein in medical terms is also called high-sensitivity C-reactive protein and Ultrasensitive C-reactive protein. The protein is a marker of low-grade inflammation and its levels can be elevated due to the existence of any inflammatory condition in the body. It can be caused by a wide variety of conditions, from infection to cancer, and can result in cardiovascular diseases such as heart stroke, etc.

What does it mean to have a high CRP?

It can be caused due to plethora of conditions including pregnancy, infections and cancer. The physician believe that high levels of C-reactive protein in the blood increases the chances of a heart disease and attack. High levels of CRP also indicate the development of diabetes in an individual. If your result shows a high CRP levels, it would be appropriate to consult your physician for further tests which maybe required.

What is CRP test?

It is done to measure the level of inflammation in your body (i.e. CRP). Though a CRP cannot show where the inflammation is actually, or what is causing it; he may advise you some tests to identify these issues.

What does C- reactive protein results indicate?

  • A reading of less than 1 mg/L indicates that you are having at a lower risk of cardiovascular disease.
  • A reading between 1-2.9 mg/L indicates you are at intermediate risk.
  • A reading higher than 3 indicates you of increased risk of cardiovascular disease.
  • A reading above 10 mg/L maybe found in following conditions:
    1. Bone infection
    2. Inflammatory bowel disease
    3. Tuberculosis
    4. Cancer
    5. Other autoimmune diseases

What is lung cancer?

Lung cancer, over the years has evolved rapidly and is one of the commonest cancer affecting both men and women. Men have a slightly higher rate of incidence. The increased intake of illegal drugs, cigarette smoking and air pollution are some of the most common causes of this disease. It is a tumor that starts in cells of the lung and can spread to the other parts of the body.

The most common are of two main types
1. Non-small cell lung cancer (NSCLC). These are further of main 02 types.
The one that starts in glandular cells on the outer part of the lung is called adenocarcinoma. The other main type (other types exist too) can start within the flat, thin airways lining cells called squamous cells and this type of cancer is called squamous cell carcinoma of the lung. Squamous cell carcinoma can start in central areas of the lung and airways.

2. Small Cell Lung Cancer (SSLC)
It starts in cells that line the bronchi in the central airways so is usually more centrally located in the lung.

Non-Small Cell Lung Cancer is the most common one and approximately 85% of people who are diagnosed with lung cancer have this type. SCLC affects about 10-15% of patients with lung cancer.

Cancer of the lung might begin in an unsuspecting individual, usually with one or more risk factors and spread to destroy the lung tissue causing difficulty in breathing/ breathlessness/ blood while coughing.

Symptoms of Lung Cancer

Symptoms of lung cancer are similar to that of tuberculosis, but there are some fine line of differences between them.

  • A coughing problem that persists for more than two to three weeks.
  • Persistent pain in the chest.
  • Experiencing shortness of breath
  • Coughing out blood
  • Unexpected loss of weight
  • Headaches that last long maybe cancer spread to brain
  • Loss of memory maybe an early sign of metastasis (spread) to brain.

Lung Cancer Diagnosis

Imaging Tests –MRI, CT or PET scan helps in detecting the presence of abnormal masses in the lungs.
Sputum Cytology –It helps to examine the people who spit mucus when cough. This mucus when examined under a microscope can help detect cancer cells which maybe thrown out.
Biopsy –Biopsy or FNAC (fine needle aspiration cytology sample obtained at Bronchoscopy, Mediastinoscopy etc) and further examination of these under a microscope by a pathologist help to diagnose the cancer. A fine needle aspiration biopsy is done by a pathologist of a peripheral lesion but bronchoscopy/ thoracoscopy and other procedures are done by a pulmonologist who would further submit the sample to a pathologist. There should be immediate dispatch of these samples to the pathologist or else these deteriorate once outside the human body and cannot be appropriately assessed by a pathologist. The final diagnosis of cancer is given by a pathologist.
While imaging tests are done by Radiology centers; FNAC (fine needle aspiration cytology), biopsy or tissue diagnosis of tissue sampled at bronchoscopy, cytology of a bronchoalveolar lavage sample are done by all the major pathology labs.

Lung Cancer Treatment

It depends on the type of lung cancer detected. The pathologist, with his or her expertise and knowledge shall type the cancer as small cell type or non small cell type and possibly into certain other more well defined types. Depending upon the pathologist’s report, the oncologist (he is an MD in medicine and further specialised in cancer medical treatment) will decide on the treatment. Small cell cancer responds to chemotherapy better than radiotherapy and squamous cell carcinoma (non small cell type) does better with radiotherapy. Some decisions maybe required depending on the size of the cancer. If small and resectable, the oncologist may further refer to an oncosurgeon (he is an MS in surgery and further specialized in cancer surgery) for resection of the tumor. This resected tumor should again be sent to the pathologist for assessment and a diagnosis. This sample would be larger and help a better assessment of the type and grade of the tumor, whether margins of tissue resected are clear of the tumor. If any lymph nodes have been removed as well by the surgeon, a pathologist would be able to tell whether these are involved by the tumor. Today there are much better targeted therapies available for lung cancers. The most important fact is their early detected and correct diagnosis.

American Cancer society has now laid down screening protocols by low dose CT scans in high risk patients. Please check www.amulyalabs.com for these.

Standards of Testing in a Clinical Lab

Efficient testing on any eqpt requires scheduled running of controls, standards and calibration. Once these are in order only then should one run tests on it. Or else how would you know the report is correct? And procuring these controls standards and calibrators have a cost, from 6000 ( with a shelf life of 2 weeks after opening) for a simple haematology counter for a simple test like CBC to much more for others! Is your lab round the corner or in an outhouse of a nursing home doing it? Be safe & sure before you decide as your life depends on that blood sample you give! I do not even recommend home collection in large numbers as this is bound to compromise the sample. It’s best to walk down to your lab, talk to the pathologist and give your sample. He/she might even be able to talk to your doc to know what’s in his mind about you! Of course reports can be emailed for convenience.

Let’s debunk the pathology myths

Pathology is a branch of medical science which primarily focuses on the origin, nature and cause of disease. It involves the examination of tissues, organs, blood and body fluids in order to diagnose the disease. Many major advances have been made by pathologists from the past few years, for example, in the successful treatment of cancer, ensuring safe blood transfusions, developing vaccines against infectious diseases, etc.

Pathology plays a vital role throughout our lives, from pre-conception to post mortem. It falls under various specialities and each of these specialities has a different appeal and combination of laboratory and clinical work. The main specialities of pathology are as below:

  • Histopathology (the study of disease in human tissue through surgery, biopsy, or autopsy.)
  • Medical microbiology (the study of infection), immunology & molecular biology PCR techniques)
  • Chemical pathology ( the study of the biochemical basis of disease)
  • Haematology (the study of disorders of the blood)

Debunking the pathology myths

Results are instant
Some people believe that laboratory test results are all about a matter of few minutes – it’s not quite that simple though. It takes time to analyze the samples for pathologists. In fact the guy promising instant results might not be doing his job! There is always a prioritization done for testing. Urgent reports are provided to those more sick and serious. Some tests are routine and results could be provided the next day. Sometimes, the procedure of the test itself might be time consuming and need more time. For example tissues need to be processed for 14 hrs and thereafter blocks prepared, cut, stained and interpreted. Its obvious that this would take 2 days atleast in most cases.
Technological advances in the medical laboratories have made it possible to come up with the much quicker results, but they aren’t instant though.

It is all about blood tests

Although it is the most common sample required by the pathology labs, but pathology laboratories test wide variety of samples. These samples can be urine, saliva, sputum semen and other bodily fluids. It can be tissue extracted via biopsy.

General Practitioners are pathologists

Patients usually assume that their general practitioner performs the tests on their samples.
Pathologists are MDs who do their post graduation after basic medical MBBS degree from a medical school in India. In the USA all MDs are done after medical school. No degree is given soon after medical school in USA; these are awarded after a straight on ward MD in Anatomic and Clinical Pathology or any other field of medicine for that matter. Therefore a pathologist has done an MD in Lab Medicine and hence is a specialist trained in it. Some MBBS doctors go on to do an MD in microbiology only (field which entails study and isolation of infectious microbes i.e germs/bugs) and some MBBS doctors do exclusively clinical biochemistry which is study of biochemical tests. While microbiologists and biochemists are not able to interpret tissue changes and cancer under microscope, the MD pathologists can do all fields of Lab Medicine as they are trained in all fields of lab medicine including autopsy study.A pathologist runs a lab with help of lab technicians whom they train. These technicians directly are trained by the pathologist to do most tests on the machines/ manually. The pathologist also ensures that the technicians run quality controls on their machines on a scheduled basis and that all machines are calibrated from time to time. It is essential to get performance checks done or else any machine will give you some test result which you cannot rely upon. The quality of kits and reagents as well as maintenance of these machines is the responsibility of the pathologists. Microscopy is exclusively interpreted by a pathologist.

Pathology Lab in Mohali (Chandigarh), India

Amulya Labs Chandigarh, India is here to improve patient health with safe, hygienic, efficient, timely, equitable laboratory practices. The mission of Amulya Labs is to have a healthier population with screening and diagnostic tests. We have a strong foundation of knowledge, skill and state-of-the-art facilities and are recognized for excellence in Histopathology and Clinical Laboratory diagnosis.

FIBROIDS IN UTERUS? FACTS THAT YOU NEED TO KNOW

About 30-50% females are detected to have fibroids in their uterus. This detection maybe incidental on an ultrasound exam without the patient having problems due to it; or this detection could be very much related to your medical problems. Here are some answers which might help you.

1. What are fibroids?

These are benign tumors which develop from the involuntary muscle of the uterus. These maybe within the wall (intramural) or arise from the wall but as they grow they project into the uterine cavity (submucosal), distorting it and often causing excessive menstrual bleeding. They may also project outside the wall (serosal); some may have a stalk (peduncle) which makes the fibroid vulnerable to twisting (torsion) as a complication. If a fibroid lies near the mouth of the uterus, it might cause difficult birth due to obstruction. One may have a variable number of fibroids which usually  grow slowly. Transformation to cancer is very rare (1:1000)

2. Who is more likely to have fibroids?

There is a mild increase in predisposition in Asian and African American women as compared to western women. But these can occur in any woman.

3. What are the symptoms of fibroids?

These maybe totally without any symptoms or may cause any of the following problems besides those  listed above.

  1. Longer, more frequent, or heavy menstrual periods.
  2. Menstrual pain (cramps)
  3. Vaginal bleeding at times other than menstruation.
  4. Anemia (from blood loss)
  5. Pain —In the abdomen or lower back (often dull, heavy and aching, but may be sharp); pain during  sex
  6. Pressure —Difficulty urinating or frequent urination; Constipation, rectal pain, or difficult bowel movements
  7. Abdominal cramps
  8.  Miscarriages
  9.  Infertility (need to rule out other causes of infertility first).
  10. What complications can occur with fibroids?

4. What causes fibroids?

The causes are to some extent genetic but most often these tumors have been found to be hormone dependent (estrogen/ progesterone). Therefore fibroids may regress after menopause.

5. How are fibroids detected?

These can be detected by ultrasonography, hysteroscopy (a slender device, the hysteroscope is used to see the inside of the uterus. It is inserted through the vagina and cervix, hysterosalpingography which is a special X-ray test which may be able to detect abnormal changes in the size and shape of the uterus and fallopian tubes. Sometimes a laparoscope (a slender device inserted through a small cut in abdomen might help the doctor see the inside of the abdomen. The doctor can see fibroids on the outside of the uterus with the laparoscope. Imaging tests, such as magnetic resonance imaging and computed tomography scans, may be used but are rarely needed. Some of these tests may be used to track the growth of fibroids over time.

6. When to see a doctor if detected with fibroid?

Small fibroids may cause no problem, its only when you have symptoms listed above that you need to get them treated.

7. Is there medical treatment for fibroids?

The decision on type of treatment, medical/surgical should be taken by you after you get an appropriate advice about the best option for you. The same will depend on your clinical condition, fertility status, types , number and location of fibroids. Medical treatment is available in the form of hormones (gonadotropin-releasing hormone; GnRH agonists). These are used best upto 6 months max. They help to shrink fibroids; however these may get back to their size after stopping. Hormonal intrauterine devices may also be inserted too into the uterus.

8. What are the surgery options?

These are individualised to each case depending upon whether you have completed your family and the types of fibroid. If pregnancy is desired then a myomectomy is the best choice; wherein only selective removal of the fibroid is done.  This procedure is usually done laparoscopically (through a small cut in the abdomen) and it preserves the uterus. Hysteroscopic removal with a resectoscope is another method used to remove fibroids that protrude into the cavity of the uterus. A resectoscope is inserted through the hysteroscope. The resectoscope destroys fibroids with electricity or a laser beam. Although it cannot remove fibroids deep in the walls of the uterus, it often can control the bleeding these fibroids cause. Hysteroscopy often can be performed as an outpatient procedure (you do not have to stay overnight in the hospital). Another procedure that your doctor may recommend depending on your case is `endometrial ablation` wherein inner lining of endometrium is destroyed. Thsi maybe a choice in v small fibroids (less than 3 cm). Blocking the blood supply selectively to the fibroid which helps to shrink it is another choice and is known as ùterine artery embolisation. Magnetic resonance imaging-guided ultrasound surgery is another non invasive procedure where ultrasound waves are used to destroy fibroids; its long term cure is still under research.
If the patient has completed her family the removal of uterus along with the fibroid in it maybe the best choice.

9. How would I know if my fibroid is predisposed to cancer?

Most fibroids are benign. Certain features on imaging also reveal the same. It is important that after removal, the tissue removed is examined by a pathologist to ensure the same. There maybe certain miscroscopic features which suggest that you need a follow up. All human tissue removed at any surgery must be confirmed for its identity under a microscope by a histopathologist as per international health care standards.

10. After a myomectomy removal , how soon could a pregnancy be planned?

The best time is after 6 months although healing is complete by 3 months. 

Infections and Cancer

Certain infections if not cleared over a period of time lead to mutative changes in the cells in the organs that they infect and predispose to Cancer of these. Enlisted below are most of them. It is imperative that we get screened and remedies to clear these infections are sought in order to prevent these cancers. Most of these are viruses.

Infectious Causes of Cancer