cancer recurrence : when nose cancer returns

"Your cancer has returned. Cancer may have spread to your lung." To cancer survivors, this is probably the most devastating news. And it happened to me less than 2 years after my first cancer diagnosis.

Cancer recurrence or relapse is something that most cancer survivors hope would never happen to them. After the end of cancer treatment, no survivor would wish to go through the agony of cancer again. The second time can be more distressing than the first. But when cancer returns, what should you do?

My experience with cancer recurrence

2006 - diagnosed with Stage 2 nasopharyngeal cancer, underwent radiotherapy
2007 - CT scan picked up tiny nodules on right lung, metastasis suspected
2008 - underwent lung resection (keyhole surgery) to remove 3 malignant nodules
2010 - CT scan showed no tumour in lungs & other parts of body

What is cancer recurrence? (source : http://www.mayoclinic.com/)
When cancer returns after a period of remission, it's considered a recurrence. A cancer recurrence happens because, in spite of the best efforts to rid you of your cancer, some cells from your cancer were left behind. These cells could be in the same place where your cancer first originated, or they could be in another part of your body. These cancer cells may have been dormant for a period of time, but eventually they continued to multiply, resulting in the reappearance of the cancer.

A cancer recurrence means it's the same cancer coming back after some period of time. In rare cases you may be diagnosed with a new cancer that's completely unrelated to your first cancer. This is referred to as a second primary cancer.

Why does cancer recur? **

• tumour too big
• tumour cells resistant
• geographic miss
• cancer already spread at time of diagnosis (but too small to be picked up)

Where does cancer recur? (source : http://www.mayoclinic.com/)
Your cancer can recur in the same place it was originally located, or it can migrate to other parts of your body. Recurrence is divided into three categories:

• Local recurrence. This means the cancer reappears in the same place it was first found, or very close by. The cancer hasn't spread to the lymph nodes or other parts of the body.
• Regional recurrence. A regional recurrence occurs in the lymph nodes and tissue located in the vicinity of your original cancer.
• Distant recurrence. This refers to cancer that has spread (metastasized) to areas farther away from where your cancer was first located.

Where your cancer recurs depends on your original cancer type and stage. Some cancer types commonly recur in specific areas. For recurrent nasopharyngeal cancer (NPC), the common sites of relapse are ** :

• nasopharynx
• neck
• distant sites (esp lung, liver & bones)
• combinations of above

Ways cancer spreads (source : http://www.cancer.gov/)
Cancer can spread in 3 ways :

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Recurrent nasopharyngeal cancer (NPC) (source : http://www.cancer.gov/)
Recurrent nasopharyngeal cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the nasopharynx or in other parts of the body.

Treatment options for recurrent NPC (source : http://www.cancer.net/)
Recurrent NPC is treated with radiation therapy, chemotherapy, or in some instances, surgery. Chemotherapy is used for people whose cancer has recurred in distant sites and who were previously treated with radiation therapy only. Chemotherapy may also be used together with radiation therapy (chemoradiotherapy) to improve the effectiveness of the radiation therapy. In addition, a clinical trial of biologic therapy may be an option.

The following factors may influence the treatment options **:

• disease-free duration - if less than one year, usually no radiotherapy
• extent of recurrence - if too large, radiotherapy is not feasible
• number of previous radiotherapy - not more than 2 courses of RT can be given per patient's lifetime

NPC metastases **

• affect 30% or more of NPC survivors
• bone is most frequent site, followed by lung & liver
• most appear within 18 months of first cancer diagnosis
• usually treated with chemotherapy
• cure & long-term survival possible in some cases

References
** Notes taken from a talk presented by Dr T Tan at NPC support group in Apr 2009 on "Management of NPC Recurrence".

MayoClinic
http://www.mayoclinic.com/health/cancer/CA00050
National Cancer Institite, USA
http://www.cancer.gov/cancertopics/pdq/treatment/nasopharyngeal/Patient/page2
American Society of Clinical Oncology
http://www.cancer.net/patient/Cancer+Types/Nasopharyngeal+Cancer

cancer and side effects : overcoming side effects of radiotherapy

Most nasopharyngeal or nose cancer patients will experience some side effects of radiotherapy. The side effects usually appear gradually during the course of radiotherapy & might be at their worst at the end of the treatment. Different people react differently to radiotherapy. The intensity & severity of the side effects may be influenced by the following factors ** :

• radiation dose
• energy source
• volume of tissue treated
• radiotherapy techniques & regimen
• pre-treatment periodontal condition (area around the teeth)
• the patient's body constitution (eg size, weight, health status, muscle buffer)

There are early & late side effects of radiotherapy.

Early Side Effects

Some early side effects may vanish when treatment ends but some may linger for weeks, months or even years. Early side effects of radiotherapy include the following ** :

• oral mucositis (mouth ulcers)
• taste dysfunction
• reduced sense of smell
• xerostomia (dry mouth)
• skin blisters & burns
• difficulty chewing & swallowing (due to pain & inflammation)
• fungal infections in oral cavity

Late Side Effects

Late side effects can appear months or years after the end of radiotherapy. Late side effects of radiotherapy include the following ** :

• oral complications
• otologic (ear) complications
• opthalmic (eye) complications
• radiation induced cancers
• pituitary (endocrine) problems
• swallowing problems
• neck stiffness & ache
• numbness of hands, neck, face
• loss of sense of smell

My experience with early side effects

1. Xerostomia (dry mouth caused by radiation damage to the salivary glands). My mouth became dry gradually as radiation progressed from Day 1 to Day 33. By the end of the 33 sessions of radiation, my mouth had near-zero saliva, as dry as the Sahara desert. It was unbearable. Today, almost 4 years later, I would say my saliva has come back about 80%. The salivary glands, which were destroyed & damaged by radiation, had healed gradually over the years, although not to the 100% pre-cancer level.
2. Oral mucositis (mouth ulcers). By Day 8 of radiotherapy, the first ulcer appeared in my mouth. Over the next 2 months, the ulcers multiplied by the hundreds all over my mouth -- walls of the mouth, palate, tongue, throat, gums. It was painful. I found it difficult to eat or drink through the mouth.
3. Saliva. My glue-like saliva became thicker by the day. By Day 13, my salivary glands had been bombed so badly by radiation that volumes of thick saliva were flowing out of my mouth 24/7 for about a month. I had to continuously spit it out as it was impossible to swallow the sticky saliva. As I could not eat or drink, I had to reluctantly agree to have a feeding tube inserted through the nose. My main concern at this time was that even if I didn't die of cancer, I might die of starvation or malnutrition. I survived through liquid food fed through the tube. I became very self-conscious of my looks as the feeding tube made me look like a monster from outer space. It affected my self-esteem. I felt lousy.
4. Difficulty talking. The non-stop outflow of saliva affected my ability to talk. I had to use pen and paper method to communicate with others. Sleeping was a problem as I had to slant my face sideways to allow the saliva to flow out onto pieces of tissue paper. I had broken sleep every night.
5. Fungal infection in oral cavity. The dry mouth effect caused fungus to grow on my tongue. I was put on Nystatin & Fluconazole medication to minimise infection.
6. Nausea. I suffered from nausea throughout the radiotherapy. By Day 18, the nausea became so bad that I had to be hospitalised for acute dehydration.
7. Constipation. I was put on medication to relieve the pain caused by ulcers. As a result, I suffered from constipation which became so serious by Day 25 that I had to be hospitalised a second time.

My experience with late side-effects

1. Dental caries (tooth decay). One to two years after radiation, I began to experience some signs of tooth decay. I suffered from toothache, cavities & broken teeth. I had undergone several root canal operations & dental treatments at the Singapore National Dental Centre. To protect my teeth from further decay, I use a tooth tray to apply tooth mousse on my teeth & gums when I sleep at night. The tooth mousse also helps to keep my mouth moist throughout the night. As a result, I experience less dental problems now.

References

** Notes taken from a talk presented by Dr Tham @ NPC support group in 2007 on "Coping with the side effects of radiotherapy for Nasopharyngeal Cancer".

CancerHelp UK

http://www.cancerhelp.org.uk/type/nasal-cancer/treatment/radiotherapy/side-effects-of-nasal-and-sinus-cancer-radiotherapy