Cancer of the spine

CANCER is not a word that any of us take lightly; often times the term equals death in our minds, despite the strides that have been taken in medicine in treating cancer.

The disease is caused by rapid and abnormal cell divisions that result in a tumour, which ends up choking the organ, and eventually, the body.

A benign tumour - like a large mole on the skin - is not life-threatening, whereas a malignant tumour continues to grow and brings about death, if treatment is not sought.

The metastasis of cancer essentially means the movement of cancer cells from the primary site of growth to other parts of the body through the bloodstream, causing secondary tumours, and even, tertiary ones.

Cancer can occur in any part of the body, and though there is treatment for these cancers, not all are effective.

Certain organs, like the liver and pancreas, are harder to treat and cure because they are such crucial organs to life, and they are also easy targets for metastasis.

The spinal cord is another such organ.

In a healthy human, the spinal cord monitors, collects and sends information from the body to the brain for processing.

Together, the brain and the spinal cord make up the central nervous system. This delicate structure is protected by the spine, which is made up of vertebrae and the skull.

Cancer can occur in the spine either as a primary cancer, or through metastasis, which results in a secondary cancer.

Cancer of the spine requires urgent attention. If left untreated, the cancer cells can destroy the spinal bones (vertebrae), causing enormous pain, and also, instability of the spinal column.

In some cases, collapse of the vertebrae is a possible result. When this happens, the cancerous mass may compress the spinal cord or the spinal nerves, resulting in pain, paralysis, sensory failure, and loss of bowel or bladder control.

A world of pain

A world of pain

Spinal cancers can be extremely painful in the late stages. According to Baltimore-based healthcare service provider Lifebridge Health in the US:

"For the patients who develop symptoms, understanding the treatment options and choosing the most appropriate one can be very stressful and confusing."

Depending on the type and stage of the spinal cancer, various forms of treatment modalities are available today, ranging from chemotherapy and radiotherapy aimed at destroying the cancerous cells to surgical treatment.

When combined together, surgery plus radiotherapy can potentially give the best possible outcome to some patients.

"When metastasis occurs, the spine is an easy target," says Dr Mohd Hisam Muhamad Ariffin, orthopaedic and spine surgeon at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in Cheras, Kuala Lumpur.

There is no specific data regarding spinal cancer in Malaysia. However, according to LifeBridge Health, spinal metastasis occurs in about 70 per cent of cancer patients.

In an autopsy study, spinal metastasis was found in nearly 90 per cent of cancer patients.

In the United States, about 18,000 cases are diagnosed with spinal metastasis annually.

Symptoms of spinal cancers include mild to excruciating pain, which is typically pain that can wake you up from sleep. Sometimes, this type of pain can be mistaken for arthritis or muscular spasms.

"Cancers of the spine can result in the patient having compressed nerves or (compression of the) spinal cord; (vertebral) bones become destroyed from the cancer and can't hold the person's body upright anymore.

"This results in the patient being immobile, (either) from pain or from being paralysed due to the spinal cord compression.

"They can also feel a lot of pain and the patient has a very poor quality of life," explains Dr Hisam.

Moreover, if the cancer is detected late, and it is in its advanced stage, surgery is usually not recommended by doctors.

Most treatment at this point is for pain management and keeping patients as comfortable as possible.

"At present, some doctors are of the opinion that as the cancer is incurable, carrying out the surgery is a waste of time and money. Besides, the know-how to do so is limited to particular medical centres.

"But with the increase in cancer occurrence, including cancer of the spine, more and more people are facing the decision of whether (or not) to opt for surgery," says Dr Hisam.

He adds that he advocates improving the quality of the patient's life, which should be the priority for the patient's caregivers.

Quality of life

Improving quality of life

According to Dr Hisam, there are many ways of helping improve the patient's quality of life.

Currently, when a patient comes with a simple compression fracture from spinal metastasis, doctors would suggest the use of a brace, a short course of radiotherapy, or sometimes, a simple surgical procedure called a vertebroplasty or kyphoplasty.

In this procedure, cement is injected into the destroyed vertebrae through small needles inserted into the spine, using X-rays for guidance.

The injected cement has two functions, to make the diseased bone stronger and to relieve pain.

For spinal cancer patients who suffer from paralysis due to spinal cord compression, and eventually, the destruction of the spinal co-lumn, Dr Hisam advocates surgery to remove the compression from the spinal cord.

According to him, most doctors use titanium metal implants to stabilise the column.

The surgery can be performed via the traditional open method or using minimally-invasive spine surgery.

In the latter, metal implants are inserted via small incisions, utilising special instruments.

After the surgery, patients are normally scheduled to undergo a short course of radiotherapy.

For Dr Hisam, opting for metal implants to increase the patient's quality of life makes sense.

"If the patient is fit for surgery and the money is available, patients should consider undergoing surgical treatment to improve their quality of life," he says.

In his opinion, to be able to sit up and walk, even if it is just around the house, is a great boost for the patient.

Furthermore, pain is also reduced, and their bowel and bladder can be controlled, which is a big improvement for the patient.

"We want to educate patients with such medical conditions on why they should consider intervention via surgery and radiotherapy, even if the patient is terminal," he says.

High quality innovative spinal implants are available in Malaysia, but the cost of the titanium implants can be expensive. Patients and their family will have to weigh the cost carefully.

However, for civil servants and pensioners, the Government will bear the cost of the implants for procedures done at public hospitals, like UKMMC.