understanding nose cancer : staging

When the MRI results came out, my oncologist told me the tumour was Stage "T2N0" NPC. Do you know what it means? At that time, I didn't quite understand the staging process for NPC. I will share what I've learned from the internet library. What is staging & why is staging necessary?

Staging is the process used to find out whether cancer has spread within the nasopharynx or to other parts of the body. The information gathered from the staging process determines the stage of the disease. The results of the tests used to diagnose NPC are often used to stage the disease. It is important to know the stage in order for your oncologist to plan your treatment. (http://www.medicinenet.com/)

I believe that in Singapore, we use the AJCC TNM staging system. I obtain information about this system from the American Cancer Society website. (http://www.cancer.org/)

The American Joint Committee on Cancer (AJCC) TNM system
A staging system is a standardized way for members of the cancer care team to summarize the extent of a cancer's spread. The most common system used to describe the spread of NPC is the TNM system created by the American Joint Committee on Cancer (AJCC). This system contains 3 key pieces of information :

• T describes whether the primary tumor has invaded other organs or tissues near the nasopharynx.
• N describes whether the cancer has spread to nearby (regional) lymph nodes (bean-sized collections of immune system cells located throughout the body).
• M indicates whether the cancer has metastasized (spread) to other organs of the body. (The most common sites of distant nasopharyngeal cancer spread are the lungs, liver, and bones.)

The numbers or letters that appear after T, N, and M provide more details about each of these factors :

• The numbers 0 through 4 indicate increasing severity.
• The letter X means "cannot be assessed" because the information is not available.
• The letters "is" after the T stand for "in situ," which means the tumor is still only in the layer of cells where it started and has not yet invaded deeper.

T groups for nasopharyngeal cancer
TX: Primary tumor cannot be assessed due to incomplete information.
T0: No evidence of a primary tumor.
Tis: Carcinoma in situ (cancer cells are present only in the surface layer of the nasopharynx but have not invaded into deeper layers).
T1: Tumor is limited to the nasopharynx.
T2: Tumor extends to tissues (but not bone) near the nasopharynx.

• T2a: Cancer extends to the oropharynx (the back of the mouth, where the throat begins) and/or nasal cavity but no farther.
• T2b: Cancer has also extended to the left or right sides of the upper part of the throat.

T3: Tumor extends to the sinuses and/or the bones near the nasopharynx.
T4: Tumor extends into the skull and/or cranial nerves (nerves in the head that lie near the nasopharynx and have special functions such as vision, smell, and eye movement), the hypopharynx (lower part of the throat), or the eye or its nearby tissues.

N groups for nasopharyngeal cancer
NX: Nearby lymph nodes cannot be assessed due to incomplete information.
N0: No spread to nearby lymph nodes.
N1: Spread to 1 or more lymph nodes, not larger than 6 cm (about 2½ inches) across, on one side of the neck.
N2: Spread to lymph nodes, not larger than 6 cm across, on both sides of the neck.
N3: Spread to 1 or more lymph nodes that are either :

• larger than 6 cm across (N3a), or
• are located just above the collarbone (N3b)

M groups for nasopharyngeal cancer
MX: Distant spread (metastasis) cannot be assessed.
M0: The cancer has not spread to tissues or organs far away from the nasopharynx.
M1: The cancer has spread to tissues or organs far away from the nasopharynx.

TNM stage grouping
Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping. The stage is expressed in Roman numerals from stage 0 (the least advanced) to stage IV (the most advanced). Some stages are subdivided with letters.

Stage 0
Tis, N0, M0 : The cancer is "in situ." It has not yet invaded into deeper layers of nasopharyngeal tissue and has not spread to nearby lymph nodes or distant sites.

Stage I
T1, N0, M0 : The tumor is only in the nasopharynx and has not spread to nearby lymph nodes or distant sites.

Stage IIA
T2a, N0, M0: The tumor has spread to soft tissues of the nasal cavity and/or the oropharynx but no farther. It has not spread to nearby lymph nodes or distant sites.

Stage IIB
There are 2 combinations of categories that make up this stage.

T2b, N0, M0 : The tumor has extended to the soft tissues of the nasal cavity and/or the oropharynx and has also extended to the left or right sides of the upper part of the throat. It has not spread to nearby lymph nodes or distant sites.

T1-T2b, N1, M0: The tumor may still be confined to the nasopharynx, or it may have extended to the soft tissues of the nasal cavity and the oropharynx and/or the left or right sides of the upper part of the throat. It has spread to one or more nearby lymph nodes, not larger than 6 cm (about 2½ inches) across, on only one side of the neck. The cancer has not spread to distant sites.

Stage III
There are 2 combinations of categories that make up this stage.

T3, N0-N1, M0 : The tumor has spread to the sinuses or the bones near the nasopharynx. It may or may not have spread to nearby lymph nodes (not larger than 6 cm across and on only one side of the neck). It has not spread to distant sites.

T1-T3, N2, M0 : The tumor may still be confined to the nasopharynx, or it may have extended to the soft tissues of the nasal cavity, the oropharynx, the left or right sides of the upper part of the throat, the sinuses, or the bones near the nasopharynx. The tumor has spread nearby lymph nodes on both sides of the neck, and none are larger than 6 cm across. The cancer has not spread to distant sites.

Stage IVA
T4, N0-N2, M0 : The tumor has extended to the skull and/or cranial nerves, the hypopharynx, the eye, or its nearby tissues. It may or may not have spread to nearby lymph nodes in the neck (none of which are larger than 6 cm across). It has not spread to distant sites.

Stage IVB
Any T, N3, M0 : The tumor may or may not have extended into nearby soft tissues or bones. It has spread to lymph nodes that are larger than 6 cm across and/or are located above the collarbone area. The cancer has not spread to distant sites.

Stage IVC
Any T, any N, M1 : The tumor may or may not have extended into nearby soft tissues or bones. It may or may not have spread to nearby lymph nodes. It has spread to distant sites.

References :
American Cancer Society
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_nasopharyngeal_cancer_staged_17.asp

understanding nose cancer : risk factors

Most people react with shock & disbelief when told they have cancer. This initial denial is a normal reaction which for some people, can last minutes, while for others days or weeks.

Cancer runs in my family. My second sister succumbed to metastatic breast cancer & died at the young age of 32, just 9 months after diagnosis. My maternal grandma died of nose cancer back in the 1960's after surviving 5 years. After my sister's death, I became more aware of cancer & immersed myself with health books to help me change my lifestyle so I would not get cancer. But I still ended up with cancer.

When I was diagnosed with nose cancer in Aug 2006, my first reaction was of disbelief. How could it be cancer? How could I have succumbed to the very disease I had worked so hard to avoid all these years? I didn't understand. I was confused. The healthy lifestyle as prescribed by health books had helped me to be in the pink of health for almost 20 years. I hardly suffered from common ailments such as colds or flus or sore throats. But I found myself suffering from the same deadly disease that had taken the lives of two of my loved ones. What went wrong?

The first question cancer patients often ask is, "How did I get cancer?" Your doctor probably gave this standard answer, "Cancer can be caused by genetic, environmental and lifestyle factors." Cancer is still a mystery disease to this day. There is no answer to the many questions many of us have.

I learn from online resources that there are risk factors for different types of cancer. A risk factor is anything that increases your risk of getting a disease. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for many kinds of cancer.

But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. Although scientists have found several risk factors that make a person more likely to develop nose cancer, many people with this cancer have no known risk factors. Even if a patient has one or more of these risk factors, it is difficult to know whether that factor actually caused the cancer.

Unlike other squamous cell cancers of the head and neck, nose cancer does not appear to be linked to excess use of tobacco and alcohol. Scientists have found several risk factors that make a person more likely to develop nose or nasopharyngeal cancer (NPC).

Ethnic background. NPC is more common in people of Chinese or Asian ancestry. For some unknown reasons, NPC is relatively rare among Caucasians, Indians & Japanese.

Exposure to the Epstein-Barr virus. EBV is a common virus that remains dormant in most people. EBV has been associated with certain cancers, including NPC & some lymphomas. But the link between EBV infection and NPC is complex and not yet completely understood. EBV infection alone is not enough to cause NPC since infection with this virus is very common. Other factors such as a person's genes may affect how the body deals with EBV, which in turn may affect how EBV contributes to the development of NPC.

Genetic factors. A person's genes may affect their risk for NPC. For example, just as people have different blood types, they also have different tissue types. Studies have found that people with certain inherited tissue types have an increased risk of developing NPC. Tissue types affect immune responses, so this may be related to how a person's body reacts to EBV infection.

Family history. If someone in your family has nose cancer, you have a 15% to 20% risk of developing the cancer. It is not known if this is because of inherited genes, shared environmental factors (such as the same diet or living quarters) or some combination of these.

Diet. A diet high in salted fish and nitrosamines, and eating a lot of fermented food.

References :

American Cancer Society http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_nasopharyngeal_cancer_17.asp?sitearea=

MedicineNet
http://www.medicinenet.com/nasopharyngeal_cancer/article.htm

Centre for Ear Nose Throat
http://www.entdoctor.com.sg/articles/nose-cancer.html

understanding nose cancer : signs & symptoms

For me, it all started with an innocent ringing tone (tinnitus) in my left ear after 2 weeks of swimming lessons. I gradually experienced blocked ear. A biopsy later confirmed I had nose or nasopharyngeal cancer (NPC). All this took place within a month.

Possible signs of nasopharyngeal cancer include trouble breathing, speaking or hearing. These and other symptoms may be caused by nasopharyngeal cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur :

• A lump in the nose or neck
• A sore throat
• Trouble breathing or speaking
• Nosebleeds
• Trouble hearing
• Pain or ringing in the ear
• Headaches

References :

National Cancer Institute, USA http://www.cancer.gov/cancertopics/pdq/treatment/nasopharyngeal/Patient/page1

cantonese cancer

At my first consultation with my NPC oncologist at the National Cancer Centre in Aug 2006, the first question he asked me was, "Are you Cantonese?" "No, I'm Hokkien," I replied, surprised at his question.

The medical name for nose cancer is nasopharyngeal cancer or NPC. Do you know that nose cancer is also referred to as "Cantonese cancer"? No wonder my oncologist asked if I was Cantonese.

Nose cancer is very common in Asia, predominantly in southern China & Hong Kong where the majority are Cantonese. That was how the nickname "Cantonese cancer" came about. Nose cancer is also prevalent in Taiwan and the Chinese communities in South-East Asia & other parts of the world. For some unknown reasons, nose cancer is relatively rare in Caucasians, Indians and Japanese.

There are approximately 300 new cases of NPC diagnosed in Singapore each year. Men are more prone to get nose cancer than women, in the ratio of 2.8 : 1. That is, almost 3 out of every 4 nose cancer cases are men. In simple language, it means that out of every 100 people with nose cancer, 75 are men & 25 are women. No wonder nose cancer is sometimes referred to as "men's cancer".

I obtained the following statistics from the respective countries' cancer register :

• Nose cancer is ranked 6th in Singapore, 2nd in Malaysia, 5th in Hong Kong & 10th in Taiwan among the most common cancers in men.
• However, nose cancer is nowhere among the Top 10 cancers for women in these countries. Breast cancer is unanimously the No.1 cancer affecting women not only in Asia but also in the world.

References :

Singapore Cancer Registry
http://www.hpb.gov.sg/uploadedFiles/HPB_Online/Publications/CancerTrends2002-2006.pdf

National Cancer Registry, Ministry of Health Malaysia
http://www.radiologymalaysia.org/Archive/NCR/2ndNCR.pdf

Hong Kong Cancer Registry, HK Hospital Authority
http://www3.ha.org.hk/cancereg/

Taiwan Cancer Registry
http://crs.cph.ntu.edu.tw/uploadimages/Leading_10.pdf

what is nasopharyngeal cancer?

At first, I did not even know that the medical name for nose cancer is nasopharyngeal cancer or NPC. I did not know anything about NPC either. Thanks to internet, I started to read up on NPC to learn more about this disease. So what exactly is NPC?


Nasopharyngeal cancer or NPC is a disease in which malignant (cancer) cells form in the tissues of the nasopharynx.


The nasopharynx is the upper part of the pharynx (throat) behind the nose. The pharynx is a hollow tube about 5 inches long that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes from the throat to the stomach). Air and food pass through the pharynx on the way to the trachea or the esophagus. The nostrils lead into the nasopharynx. An opening on each side of the nasopharynx leads into an ear. Nasopharyngeal cancer most commonly starts in the squamous cells* that line the nasopharynx.

* squamous cells = flat cell that looks like a fish scale under a microscope. These cells cover inside and outside surfaces of the body. They are found in the tissues that form the surface of the skin, the lining of the hollow organs of the body (such as the bladder, kidney, and uterus), and the passages of the respiratory and digestive tracts.

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References :
National Cancer Institute, USA
http://www.cancer.gov/cancertopics/pdq/treatment/nasopharyngeal/patient/

an experience I can never forget

I went to collect my biopsy result at a local hospital on 16 Aug 2006 but was made to wait more than an hour. Patients who were behind me in the queue were called in first. I had an inkling the biopsy result would turn out to be bad news.

I was now the only patient left in the clinic. The ENT doctor finally called for me. I walked nervously into her room. I noticed her eyes were avoiding mine as she quietly held the door for me. I looked at her & asked, "It's cancer, right?" She did not answer but asked me to take a seat.

After what seemed like ages, she finally spoke, "I'm sorry, you have nose cancer." Her voice was not steady. It seemed to me like she was trying to hold back her tears. It was not tears of sorrow, but tears of regret.


In the last one month, the ENT team in that hospital had persistently dismissed my blocked ear as nothing serious. They kept insisting there was nothing wrong with my ear, even when I told them many times, almost with tears, that my ear had become worse. The biopsy was finally done at my insistence, and only after I had made a lot of noise & warned them that I would go to another hospital. The biopsy result proved I was right after all.


Fast forward one year, after my cancer treatment, I wrote to that hospital's CEO to tell him my story. He called to apologise for the undue stress his ENT team had caused me & promised to investigate. I hope the hospital has taken steps to ensure the same mistakes do not happen to other patients. And I also hope that all doctors would learn from this unfortunate incident and make an effort to listen more to their patients.

For the record, I asked to be transferred to the National Cancer Centre at Singapore General Hospital for follow-up cancer treatment. NCC is a premier medical institution in Singapore in the treatment of cancer (http://www.nccs.com.sg/).

Valuable Advice (for the benefit of future NPC sufferers)
1. Always choose a hospital you can trust (based on what you have heard from family & friends).
2. If you prefer to be treated in a restructured hospital* as a subsidised patient, you will first need to get a referral letter from a polyclinic.
3. If your polyclinic doctor refers you to a restructured* hospital "because that hospital has no queue" but you don't feel comfortable going to that hospital, please raise your concerns with your doctor.
4. If the doctor refuses to refer you to the hospital of your choice, I suggest that you go to your preferred hospital's Accident & Emergency (A&E) dept. It may cost more (S$80 at the time of writing) but it may save you your life. 

useful notes :
In Singapore, if you intend to consult a medical specialist in a restructured hospital & be treated as a subsidised** patient, you will need to obtain a referral letter from a government-owned polyclinic or the A&E dept of a restructured hospital.

* A restructured hospital is a public hospital.

** As a subsidised patient, your medical bill will be subsidised by the Ministry of Health (the government), so you will not have to pay the full medical bill. If you are hospitalised, you can choose to stay in a Class B2 or C ward. A "private" patient, however, will have to pay the full medical bill and can choose to stay in a Class A or B1 ward.

10 killer facts on cancer

• There are more than 100 types of cancer; any part of the body can be affected.
• Cancer accounted for 7.9 million deaths worldwide (around 13% of all deaths) in 2007.
• Deaths from cancer are projected to rise to 12 million worldwide by 2030.
• The 5 most common types of cancer that kill men worldwide are lung, stomach, liver, colorectal and esophagus.
• The 5 most common types of cancer that kill women are breast, lung, stomach, colorectal and cervical.
• About 72% of all cancer deaths in 2007 occurred in low- and middle-income countries.
• WHO estimates that 30% of cancers can be prevented, mainly by not using tobacco, having a healthy diet and being physically active.
• Tobacco use is the single largest preventable cause of cancer in the world.
• A third of cancers could be cured if detected early and treated adequately.
• A fifth of all cancers in the world are caused by chronic infection, eg human papillomavirus (HPV) causes cervical cancer & hepatitis B virus (HBV) causes liver cancer.

References :

http://edition.cnn.com/2009/HEALTH/01/29/cancer.facts/

updated as at 29 Jan 2009

why I started this blog

I read the CT Scan report again and again. The report was two-pages long but only these few words kept staring back at me : "suspicious of pulmonary metastases.”

It was March 2008. I was with my oncologist who had gone through the results with me. I wished there was a mistake but the report was right before me. Yes, it seemed like I had suffered a cancer recurrence. Yes, it looked like the nasopharyngeal cancer I was diagnosed with in Aug 2006 had spread to my right lung. My cancer had returned.

Many questions went through my mind. Did I do anything wrong? What should I have done or not done to prevent this relapse? Was there any part in my life I needed to change to make sure I will win this battle against cancer?

This unexpected relapse was a wake up call. I started to reflect on what I had done or not done over the past one-and-a-half years. For the most part of my post-recovery period, I had turned to TCM (Traditional Chinese Medicine) to help me regain my lost strength and immunity. I had made an effort to drink fresh vegetable juices daily with the belief that they could help detoxify my body of toxins. And I had tried to follow dietary advice given by professional nutritionists and cancer survivors.

Despite having done all these, I still felt lost and confused. I was not sure if I was doing the right thing. It seemed that everyone had their own views on what was good or bad for cancer. I had also received many viral emails that made recommendations on what to eat or what not to eat, with some emails even claiming that a certain food could cure cancer. In this internet age, how would we know what is true and what is fake information?

This unexpected cancer recurrence prompted me to do my own serious research. I was determined to find out for myself what I should do or not do to prevent another cancer recurrence. I was determined to search for “true and reliable” information from reliable sources. I will record all this information and share it with all cancer sufferers, in particular those with nasopharyngeal or nose cancer (NPC).

And so this blog was born out of this desire to share. It is free. It is easily accessible by anyone, anywhere, anytime. And if God should decide to take me home one day, this blog can live on as a legacy for future cancer sufferers.

your fellow NPC survivor,
shuqin