Long ago, there were politicians who advocated spending large sums of money on medical research, specifically with the goal of waging and winning “the war against cancer.” That appealed to many of us, especially the many whose lives had been touched directly or through family and friends by this all too common scourge.
Perhaps a better analogy might be to compare the fight against cancer to a police action rather than a military engagement, in which civilian law enforcers try to round up those members of our own community who refuse to live by the rules and thereby protect the majority who are law abiding.
This model is actually very close to the behavior of cancer cells within the community of healthy cells, where certain renegade cells lose the normal constraints and inhibitions that regulate healthy cells and begin to grow without limit, even spreading through our blood to far distant sites from where they first originated.
Who are the law officers trying to keep these “bad apples” in check? Why they are your family doctor, nurse practitioner, and a host of medical specialists and allied health professionals, most of whom are represented on the staff at Brattleboro Memorial Hospital.
Among those specialists are the diagnostic radiologists who are helping their colleagues to identify cancers that appear within us, sometimes quite slowly and insidiously, sometimes with terrifying boldness and aggressive behavior. And after these villains are identified, the radiologist can further assist by monitoring for success of therapy or recurrence.
Radiologists need to have a thorough knowledge of the normal anatomy in order to recognize when something unwanted is present. It’s as if we carry a huge rolodex of mug shots in our heads (and in our reference sources) to which we constantly compare potential interlopers. Sometimes these sleazy characters are part of the group called the “usual suspects,” the common cancers. Sometimes they are rare and exotic or well disguised.
The search for these rogues falls into two broad categories: (1) screening the asymptomatic individual for purposes of earliest detection, and (2) searching for a cause of symptoms in those already clinically ill. Both are important. Screening has the advantage of detecting cancer at an earlier stage before it has caused symptoms, ideally the earliest stage at which our modern knowledge and technology permit.
The single best known area in which we screen is at the BMH Breast Care Center, where we use mammography (an x-ray technique), ultrasound (sound waves), and now MR or magnetic resonance (magnetic fields and radio waves) to obtain images of the breast for the purpose of detecting changes suspicious for cancer.
Suspicious findings in the breast can be biopsied using stereotactic (x-ray guided), ultrasound guided, or even MR guided approaches by the BMH radiologists and surgeons. None of these techniques replaces the others; rather they complement each other depending on the particular patient.
Cancers of the lung, abdominal organs (for example: liver, pancreas, kidneys), lymph nodes, and neck are most often detected using CT scanning, combining x-rays with advanced computers to create detailed images of our inner anatomy without breaking the skin.
Cancers of the thyroid and female pelvic organs are most often first approached with ultrasound, utilizing sound waves that are again processed using state-of-the-art computers to create images, including some that move in real time.
Colon cancer is most often found today using endoscopy, but CT scans play an important role in excluding spread of the tumor at time of diagnosis. Similarly, prostate cancer, which may be suspected from lab tests or physical exam, is often diagnosed by ultrasound guided biopsies, while evidence of spread of tumor at time of diagnosis is often sought using nuclear bone scans and CT scans.
CT and ultrasound frequently are used to guide radiologists as they perform biopsies through the skin using fine needles in various parts of the body.
In addition to these methods for initial diagnosis or staging (determining how far advanced a newly diagnosed cancer may be), it is very important to follow patients after surgery or chemotherapy or radiation therapy to see how the tumor responds, whether it recurs, or whether it spreads (called metastasis). Here all the techniques used for earlier diagnosis play a potential role.
Perhaps chief among the follow-up techniques is the CT scan, which combines a wide field of view with great anatomic detail and very high reproducibility, making it highly useful to compare from study to study over time.
The four board-certified radiologists at BMH, including myself, Drs. Edward Elliott, Peter Gibbons, and Mariusz Paluch, serve to advise patient’s care providers regarding the appropriate choice of exams for particular purposes as well as interpreting those exams. They work in close coordination with BMH surgeons and oncologists. BMH is also affiliated with the Cotton Cancer Center at Dartmouth Hitchcock Medical Center. Appropriate referrals are made to outside institutions for those few technologies such as radiation therapy which are not offered at BMH.
Working together as a team, we can not only succeed in the first step by “putting a face to cancer,” but maximize the chance of turning each newly diagnosed patient into something much better – a survivor.
Walter Wagenknecht, MD is a board-certified radiologist at Brattleboro Memorial Hospital. He can be reached at 802-257-8820.